PN FA cases

Closure

"There are several measures you can take that may prevent you from having a clot. Above all, you should avoid immobilization for long periods of time—for example, while sitting at your computer desk or on long-distance plane trips. Try to move in place and perhaps take a short walk. If you are on oral contraceptive pills, I strongly recommend that you stop taking them, as they are known to precipitate clotting. Studies have also shown that obesity increases your risk of having a clot, so I suggest that you exercise regularly and manage your diet."

Physical Examination Patient is in no acute distress. VS: WNL except for low-grade fever. HEENT: Nose, mouth, and pharynx WNL. Neck: No JVD, no lymphadenopathy. Chest: Increase in tactile fremitus and decrease in breath sounds on the right side. No rhonchi, rales, or wheezing. Heart: Apical impulse not displaced; RRR; normal S1/S2; no murmurs, rubs, or gallops. Extremities: No cyanosis or edema.

# 1: Pneumonia History Finding(s): - Persistent cough - Low-grade fever Physical Exam Finding(s): - Increased tactile fremitus -Decreased breath sounds on the right -Temperature 99.9°F #2: URI-associated cough (postinfectious cough) History Finding(s): - Recent URI - Low-grade fever - Persistent cough Physical Exam Finding(s): - Temperature 99.9°F #3: Acute bronchitis History Finding(s): -Low-grade fever -Persistent cough -White sputum production Physical Exam Finding(s): -Increased tactile fremitus -Temperature 99.9°F

=> Physical Examination - Patient is in no acute distress. - VS: WNL. - Chest: Clear breath sounds bilaterally. - Heart: RRR; normal S1/S2; no murmurs, rubs, or gallops. - Abdomen: Soft, nondistended, nontender, BS, no hepatosplenomegaly. Mild right CVA tenderness. - Extremities: No edema.

##1: Bladder cancer => History Finding(s): - Hematuria - Straining on urination - Weak urinary stream and dribbling - Works as painter (exposure to industrial solvents) - History of smoking 1 PPD × 30 years ##2: Urolithiasis => History Finding(s): - Hematuria - Straining on urination => Physical Exam Finding(s): - CVA tenderness ##3: Benign prostatic hypertrophy => History Finding(s): - Polyuria, nocturia - Weak urinary stream and dribbling - Straining on urination

Physical Examination: Patient is in no acute distress. VS: WNL. Chest: No tenderness, clear breath sounds bilaterally. Heart: RRR; normal S1/S2; no murmurs, rubs, or gallops. Abdomen: Soft, nondistended, C-section scar, epigastric tenderness without rebound, Murphy's sign, BS, no hepatosplenomegaly

##1: Cholecystitis History Finding(s): - Pain is exacerbated by heavy, fatty foods -Associated with nausea and vomiting - Female gender, age in 40s Physical Exam Finding(s) - Epigastric tenderness - Positive Murphy's sign ##2: Peptic ulcer disease >History Finding(s): - History of NSAID use -Epigastric pain 2−3 hours after meals - Pain is exacerbated by hunger and fatty foods and is relieved by antacids >Physical Exam Finding(s): - Epigastric tenderness ##3: Gastritis >History Finding(s): -History of NSAID use -Epigastric pain associated with food -Nausea and vomiting >Physical Exam Finding(s): -Epigastric tenderness

Physical Examination Patient is in mild distress due to back pain. VS: WNL. Back: Mild paraspinal muscle tenderness bilaterally, normal range of motion, no warmth or erythema. Extremities: 2+ popliteal, dorsalis pedis, and posterior tibial pulses bilaterally. Hips normal, nontender range of motion bilaterally. Neuro: Motor: Strength 5/5 throughout, including left great toe dorsiflexion. DTRs: 2+ symmetric, (-) Babinski bilaterally. Gait: Normal (including toe and heel walking), although he walks with back slightly bent forward. Straight leg raising (-) bilaterally. Sensation: Intact.

##1: Disk herniation ==> History Finding(s): - Low back pain - Pain started after lifting heavy boxes - Pain radiates to left thigh and foot - Pain worsens with movement and is relieved by lying still ##2: Lumbar spinal stenosis ==> History Finding(s): - History of intermittent low back pain and leg pain with ambulation - Pain resolves with sitting ==> Physical Exam Finding(s): Walks with back slightly bent forward ##3: Metastatic prostate cancer ==> History Finding(s): - Difficulty urinating - Incomplete emptying of the bladder - Low back pain

Physical Examination None.

#1: Acute otitis media History Finding(s): -Fever (101°F) -Pulling at right ear; fatigued and not watching TV as usual -History of otitis media -Runny nose and cough that have subsided #2: Meningococcal meningitis History Finding(s): -Maculopapular facial rash that spread to the chest, back, and abdomen -Fever (101°F) -Difficulty sleeping for 2 days -Recent episode of vomiting #3: Scarlet fever History Finding(s): -Maculopapular facial rash that spread to the chest, back, and abdomen -Fever (101°F) -Difficulty swallowing for 2 days

==> Physical Examination - Patient is in no acute distress. - VS: WNL. - HEENT: Normocephalic, atraumatic, no bruises. - Neck: Supple, full range of motion in all directions, no bruises. Chest: Clear breath sounds bilaterally. - Heart: RRR; normal S1/S2; no murmurs, rubs, or gallops. - Extremities: Right arm held closely against chest wall. Nonlocalized tenderness over middle and upper right arm and right shoulder; pain and restricted range of motion on flexion, extension, abduction, and external rotation of right shoulder. Right elbow and wrist are normal. Pulses normal and symmetric in brachial and radial arteries. Unable to assess muscle strength due to pain. DTRs intact and symmetric. Sensation intact to pinprick and soft touch.

##1: Humeral fracture ==> History Finding(s): - Pain following recent fall on outstretched arm - Tenderness over upper and middle right arm - Pain increases with arm movement - Restricted range of motion ##2: Shoulder dislocation ==> History Finding(s): - Pain following recent fall on outstretched arm - Pain increases with arm movement ==> Physical Exam Finding(s): -Right arm externally rotated and slightly abducted - Pain and restricted range of motion on shoulder exam ##3: Osteoporosis ==> History Finding(s): - Advanced age

==>Physical Examination - Patient is in no distress. - VS: WNL. - HEENT: PERRLA, no funduscopic abnormalities. - Neck: No carotid bruits, no JVD. - Chest: Clear breath sounds bilaterally. - Heart: Apical impulse not displaced; RRR; normal S1/S2; no murmurs, rubs, or gallops. - Abdomen: Soft, nondistended, nontender, BS, no bruits, no organomegaly. Extremities: No edema, no skin breakdown, 2+ dorsalis pedis pulses. - Neuro: Motor: Strength 5/5 in bilateral lower extremities. DTRs: Symmetric 2+ knee jerks, absent ankle jerks and Babinski bilaterally. Sensation: Decreased pinprick; soft touch, vibratory, and position sense in bilateral lower extremities.

##1: Insulin-induced hypoglycemia => History Finding(s) -Episodes of palpitations and diaphoresis that resolve with drinking orange juice - Tight glycemic control ##2: Diabetic peripheral neuropathy => History Finding(s) - History of diabetes mellitus - Constant numbness and tingling in feet =>Physical Exam Finding(s) - Absent ankle jerk ##3: Organic erectile dysfunction History Finding(s) - Loss of erection for 2 years with absence of early-morning erection -History of diabetes mellitus - History of alcohol use - Taking lovastatin and atenolol

Physical Examination Patient is in severe pain. VS: WNL. HEENT: NC/AT, nontender to palpation, PERRLA, EOMI, no papilledema, no nasal congestion, no pharyngeal erythema or exudates, dentition good. Neck: Supple, no lymphadenopathy. Chest: Clear breath sounds bilaterally. Heart: RRR; normal S1/S2; no murmurs, rubs, or gallops. Neuro: Mental status: Alert and oriented × 3, good concentration. Cranial nerves: 2-12 grossly intact. Motor: Strength 5/5 throughout. DTRs: 2+ intact, symmetric.

##1: Migraine >History Finding(s): -Unilateral, sharp headaches -Associated with nausea and vomiting - Photophobia >Physical Exam Finding(s): - Severe pain with lack of neurologic findings ##2: Tension headache >History Finding(s): -Chronic headaches -Associated with stress at work -Improve with sleep >Physical Exam Finding(s): -Severe pain with lack of neurologic findings ##3: Intracranial mass lesion History Finding(s): -Headaches associated with nausea and vomiting - Family history of brain tumor

>>Physical Examination: >Patient is in severe pain. >VS: BP 165/85 mm Hg (both arms), RR 22/minute. >Neck: No JVD, no bruits. >Chest: No tenderness, clear symmetric breath sounds bilaterally. >Heart: Apical impulse not displaced; RRR; normal S1/S2; no murmurs, rubs, or gallops. >Abdomen: Soft, nondistended, nontender, BS, no hepatosplenomegaly. >Extremities: No edema, peripheral pulses 2+ and symmetric.

##1: Myocardial ischemia or infarction => History Finding(s): - Pressure-like substernal chest pain - Pain radiates to left arm, upper back, and neck - Pain awakens patient at night => Physical Exam Finding(s): - None ##2: Cocaine-induced myocardial ischemia => History Finding(s): - History of cocaine use - Last used yesterday afternoon -Pressure-like substernal chest pain

==> Physical Examination - Patient appears comfortable. - VS: WNL. - HEENT: NC/AT, PERRLA, no icterus, no pallor, mouth and oropharynx normal. - Neck: No thyroid enlargement. - Chest: Clear breath sounds bilaterally. - Heart: RRR; normal S1/S2; no murmurs, rubs, or gallops. - Abdomen: Soft, nontender, nondistended, BS, no evidence of guarding or hepatosplenomegaly.

##1: Normal pregnancy ==> History Finding(s): - Amenorrhea for 6 weeks - Positive pregnancy test - Bilateral breast engorgement - Nausea and weight gain ##2: Ectopic pregnancy ==> History Finding(s): - Amenorrhea for 6 weeks - Positive pregnancy test ##3: Molar pregnancy ==> History Finding(s): -Positive pregnancy test - Nausea

==> Physical Examination - Patient is in acute distress, dyspneic. - VS: Temp 100°F, RR 22/minute. - HEENT: No JVD, no bruises, PERRLA, EOMI, no pharyngeal edema or exudates. - Chest: Two large bruises on left chest, left rib tenderness, decreased breath sounds over left lung field, right lung fields clear. - Heart: RRR; normal S1/S2; no murmurs, rubs, or gallops. - Abdomen: Soft, nondistended, BS, LUQ tenderness, no rebound or guarding, no organomegaly. - Skin: No bruises or lacerations. - Neuro: Mental status: Alert and oriented × 3. - Cranial nerves: 2-12 grossly intact. Motor: Strength 5/5 in all muscle groups. Sensation: Intact to pinprick and soft touch.

##1: Pneumothorax ==> History Finding(s): - Left-sided chest pain following an MVA - Pain is exacerbated by movement and deep breaths ==>Physical Exam Finding(s): -Decreased breath sounds over left lung field - RR 22/minute ##2: Hemothorax ==>History Finding(s): - Left-sided chest pain following an MVA - Dyspnea - Cough ==> Physical Exam Finding(s): - Decreased breath sounds over left lung field - RR 22/minute ##3: Pneumonia ==> History Finding(s): - Unilateral chest pain - Productive cough - Low-grade fever ==> Physical Exam Finding(s): - Temperature 100°F - RR 22/minute

==> Physical Examination Patient is anxious and in acute distress. -VS: WNL. - HEENT: No JVD, PERRLA, EOMI. - Chest: Clear breath sounds bilaterally; tenderness on palpation of right chest wall. - Heart: Normal S1/S2; no murmurs, rubs, or gallops. - Abdomen: Soft, nontender, nondistended, BS, no rebound or organomegaly. - Neuro: Mental status: Alert and oriented × 3. Cranial nerves: 2-12 grossly intact. Motor: Strength 5/5 in all muscle groups.

##1: Rib fracture ==>History Finding(s) - Physical assault - Right chest pain - Pain is exacerbated by movement and deep breaths ==> Physical Exam Finding(s) - Tenderness on palpation of right chest wall ##2: STD ==> History Finding(s) - Sexual assault by 2 men - No condom use ##3: Pregnancy ==>History Finding(s) - Unprotected vaginal intercourse with possible ejaculation - No OCP use - Last menstrual period 3 weeks ago

==> Physical Examination: - None

##1: Type 1 diabetes mellitus ==> History Finding(s): -Polyuria, polydipsia - Recent weight loss - Hyperglycemia ##2: Type 2 diabetes mellitus ==> History Finding(s): - Polyuria, polydipsia - Obesity -Hyperglycemia ##3: Secondary causes of diabetes (eg, Cushing's syndrome) ==>History Finding(s): - Obesity

Physical Examination Patient is in no acute distress. VS: WNL, no orthostatic changes. HEENT: Normocephalic, atraumatic, PERRLA, no funduscopic abnormalities. Neck: Supple, no carotid bruits. Chest: Clear breath sounds bilaterally. Heart: RRR; normal S1/S2; no murmurs, rubs, or gallops. Abdomen: Soft, nondistended, nontender, no hepatosplenomegaly. Neuro: Mental status: Alert and oriented × 3, spells backward but can't recall 3 items. Cranial nerves: 2-12 intact. Motor: Strength 5/5 in all muscle groups except 3/5 in left arm. DTRs: Asymmetric 3+ in left upper and lower extremities, 1+ in the right, Babinski bilaterally. Cerebellar: Romberg. Gait: Normal. Sensation: Intact to pinprick and soft touch.

#1: Alzheimer's disease History Finding(s): -Steady cognitive decline -Memory impairment -Impaired executive functioning - Decline in activities of daily living Physical Exam Finding(s): Failed 3-item recall #2: Vascular ("multi-infarct") dementia History Finding(s): Previous stroke -History of coronary artery disease (MI) -Hypertension -Impaired executive functioning Physical Exam Finding(s): -Decreased strength in left upper extremity -DTRs 3+ in left upper and lower extremities -Positive Babinski bilaterally -Failed 3-item recall #3: Dementia syndrome of depression History Finding(s): -Dysphoria after husband's death -Impaired executive functioning -Memory impairment Physical Exam Finding(s): Failed 3-item recall

Physical Examination Patient appears anxious and restless. VS: HR 102/minute. Chest: Clear breath sounds bilaterally. Heart: Tachycardic; normal S1/S2; no murmurs, rubs, or gallops. Abdomen: Soft, nontender, nondistended, BS, no guarding, no hepatosplenomegaly. Skin: Normal, no rashes, palms moist. Neuro: Brisk reflexes.

#1: Anxiety History Finding(s): -Impaired concentration, irritability, difficulty sleeping, muscle tension, sweating, and palpitations -Anxiety over academic achievement -No history of substance use Physical Exam Finding(s): - Tachycardia (HR 102/minute) #2: Caffeine-induced insomnia History Finding(s): Drinks 4−5 cups of caffeine per day -Spends 2 hours awake before falling asleep -History of palpitations that are more pronounced after -drinking caffeine Physical Exam Finding(s):Tachycardia (HR 102/minute) #3: Hyperthyroidism History Finding(s): -Anxiety -History of unintentional weight loss, fatigue, sweating, palpitations, and increased bowel movements Physical Exam Finding(s): -Tachycardia (HR 102/minute) -Brisk reflexes

Physical Examination Patient is in pain. VS: WNL except for temperature of 100.5°F. Chest: No tenderness, clear breath sounds bilaterally. Heart: RRR; normal S1/S2; no murmurs, rubs, or gallops. Abdomen: Soft, nondistended, hypoactive BS, no hepatosplenomegaly. Direct and rebound RLQ tenderness, RLQ guarding, psoas sign, Rovsing's sign, obturator sign, no CVA tenderness.

#1: Appendicitis History Finding(s): -Right lower abdominal pain tenderness -Pain is exacerbated by movement -Nausea and vomiting -Low-grade fever Physical Exam Finding(s): -RLQ direct and rebound -RLQ guarding Temperature 100.5°F -Positive Rovsing's sign -Positive psoas sign #2: Pelvic inflammatory disease History Finding(s): -STD 6 months ago with untreated partner -Nausea and vomiting -Spotting -Unprotected sex with multiple partners -Low-grade fever Physical Exam Finding(s): -RLQ tenderness -Temperature 100.5°F #3: Ruptured ectopic pregnancy History Finding(s): -Last menstrual period 5 weeks ago and spotting -Crampy lower abdominal pain -Pain is exacerbated by movement -Nausea and vomiting -Pain is of recent onset Physical Exam Finding(s): RLQ rebound tenderness RLQ guarding

Physical Examination VS: WNL. HEENT: Mouth and pharynx WNL. Neck: No JVD, no lymphadenopathy. Chest: Clear breath sounds bilaterally; no rhonchi, rales, or wheezing; tactile fremitus normal. Heart: RRR; normal S1/S2; no murmurs, rubs, or gallops. Abdomen: Soft, nontender, nondistended, BS, no hepatosplenomegaly. Extremities: No clubbing, cyanosis, or edema. Neuro: Cranial nerves: 2-12 intact. Motor: Strength 5/5 in all muscle groups. DTRs: Symmetric. Gait: Normal.

#1: COPD/chronic bronchitis History Finding(s): -Chronic cough -Sputum production -History of smoking 1 PPD × 10 years -Worked as coal miner #2: Pneumoconiosis History Finding(s): -Worked as coal miner -Chronic cough #3: Pulmonary tuberculosis History Finding(s): -Recent emigration from Africa -Chronic cough

Physical Examination Patient is in no acute distress. VS: WNL. Chest: Clear breath sounds bilaterally. Heart: RRR; normal S1/S2; no murmurs, rubs, or gallops. Abdomen: Soft, nondistended, nontender, BS, no hepatosplenomegaly.

#1: Colorectal cancer History Finding(s) -Blood mixed with stool for 1 month -Family history of colon cancer -Unintentional weight loss of 10 lbs #2: Hemorrhoids History Finding(s) -History of hemorrhoids -Hematochezia #3: C difficile colitis History Finding(s) -Acute diarrhea -Recent antibiotic exposure

Physical Examination Patient is in no acute distress. VS: WNL, no orthostatic changes. HEENT: NC/AT, PERRLA, no funduscopic abnormalities, no tongue trauma. Neck: Supple, no carotid bruits, 2+ carotid pulses with good upstroke bilaterally, thyroid normal. Chest: Clear breath sounds bilaterally. Heart: Apical impulse not displaced; RRR; normal S1/S2; no murmurs, rubs, or gallops. Extremities: Symmetric 2+ brachial, radial, and dorsalis pedis pulses bilaterally. Neuro: Cranial nerves: 2-12 grossly intact. Motor: Strength 5/5 throughout. Sensation: Intact to pinprick and soft touch bilaterally. DTRs: Symmetric 2+ in upper and lower extremities, Babinski bilaterally. Cerebellar: Romberg, finger to nose normal. Gait: Normal.

#1: Convulsive syncope History Finding(s):: -Loss of consciousness lasting several minutes -Arms and legs shaking for 30 seconds -No subsequent confusion or weak #2: Cardiac arrhythmia History Finding(s): -Loss of consciousness preceded by palpitations and lightheadedness -Taking a β-blocker (atenolol) -No subsequent confusion or weakness -History of MI #3: Seizure History Finding(s): -Loss of consciousness lasting several minutes -Arms and legs shaking for 30 seconds -Sudden onset

Physical Examination Patient is obese, in no acute distress, looks anxious. VS: WNL. HEENT: Pale conjunctivae. Neck: No lymphadenopathy, thyroid normal. Chest: Clear breath sounds bilaterally. Heart: RRR; normal S1/S2; no murmurs, rubs, or gallops. Abdomen: Soft, nondistended, nontender, BS, no hepatosplenomegaly. Extremities: Muscle strength 5/5 throughout; DTRs 2+; symmetric, painful bruises on both arms.

#1: Domestic violence History Finding(s): -Admits to physical abuse -Exhibits self-blame -Attempts to defend husband -Episode of abuse directed at child Physical Exam Finding(s): -Symmetrical bruises on extremities #2: Diabetes mellitus History Finding(s): -Polyuria, polydipsia Obesity -Family history of diabetes #3: Anemia History Finding(s): -Fatigue/weakness -Heavy menstrual flow Physical Exam Finding(s): -Conjunctival pallor

Physical Examination None.

#1: Monosymptomatic primary nocturnal enuresis History Finding(s) -Chronic nocturnal enuresis -Family history of enuresis #2: Urinary tract infection History Finding(s) -Enuresis -Possible dysuria #3: Secondary enuresis History Finding(s) -Nocturnal enuresis

Physical Examination Patient is in no acute distress. VS: WNL. HEENT: Sclerae icteric. Chest: Clear breath sounds bilaterally. Heart: RRR; normal S1/S2; no murmurs, rubs, or gallops. Abdomen: Soft, nondistended, C-section scar. Mild RUQ tenderness without rebound or guarding, Murphy's sign, BS, no organomegaly or masses. No evidence of fluid wave suggestive of ascites. Skin: Jaundice, excoriations due to scratching, no spiders/telangiectasias/palmar erythema. Extremities: No asterixis, no edema.

#1: Extrahepatic biliary obstruction (eg, pancreatic cancer, cholangiocarcinoma, ampullary carcinoma, sphincter of Oddi dysfunction) History Finding(s): -Light stools, dark urine -Pruritus -Father with pancreatic cancer Physical Exam Finding(s):- -Jaundice, scleral icterus -RUQ tenderness #2: Viral hepatitis History Finding(s): -History of blood transfusion -Recent travel to Mexico Physical Exam Finding(s): -Jaundice, scleral icterus -RUQ tenderness #3: Acetaminophen hepatotoxicity History Finding(s): -Frequent acetaminophen use -Concomitant alcohol use Physical Exam Finding(s): -Jaundice, scleral icterus -RUQ tenderness

Physical Examination None.

#1: Foreign body aspiration History Finding(s): -Sudden onset while playing with toys -Noisy breathing #2: Croup History Finding(s): -Noisy breathing -Difficulty breathing -Fever for the past week #3: Epiglottitis History Finding(s): -Occasional voice hoarseness -Occasional muffling

Physical Examination Patient is in no acute distress but favors the left knee. VS: WNL except for low-grade fever. HEENT: No oral lesions. Chest: Clear breath sounds bilaterally. Heart: RRR; normal S1/S2; no murmurs, rubs, or gallops. Abdomen: Soft, nondistended, BS, no hepatosplenomegaly. Extremities: Erythema, tenderness, pain, and restricted range of motion on flexion and extension of left knee compared to right knee. swelling at left knee. Fingers and hands with stiffness bilaterally. Shoulder, elbow, wrist, hip, and ankle joints WNL bilaterally.

#1: Gout History Finding(s): -Monoarticular joint pain and tenderness -History of swollen toe -Occasional alcohol use Physical Exam Finding(s): -Joint tenderness and stiffness -Swelling at left knee #2: Rheumatoid arthritis History Finding(s): -Morning joint stiffness -Family history of rheumatoid arthritis -Systemic symptoms (anorexia, weight loss, fatigue, fever) Physical Exam Finding(s): -Joint tenderness and stiffness -Temperature 99.9°F #3: Systemic lupus erythematosus History Finding(s): -Systemic symptoms (anorexia, weight loss, fatigue) -History of multiple oral ulcers -History of 2 spontaneous abortions -Raynaud's phenomenon Physical Exam Finding(s): -Joint tenderness and stiffness

Physical Examination Patient is in no acute distress. VS: WNL. HEENT: No conjunctival pallor, mouth and pharynx WNL. Neck: No lymphadenopathy, thyroid normal. Chest: Clear breath sounds bilaterally. Heart: RRR; normal S1/S2; no murmurs, rubs, or gallops. Abdomen: Soft, nontender, nondistended, BS, no hepatosplenomegaly. Extremities: No edema, normal DTRs in lower extremities bilaterally.

#1: Hypothyroidism History Finding(s) -Oligo- and hypomenorrhea -Chronic dry skin -Chronic cold intolerance #2: Smoking cessation History Finding(s) -Weight gain following -smoking cessassion #3: Lithium-related weight gain History Finding(s) ]-Ongoing lithium therapy

Physical Examination Patient is in no acute distress. VS: WNL. HEENT: Nose, mouth, and pharynx WNL. Neck: Supple, bilateral cervical lymphadenopathy. Chest: Clear breath sounds bilaterally. Heart: RRR; normal S1/S2; no murmurs, rubs, or gallops. Abdomen: Soft, nondistended, BS, no hepatosplenomegaly, mild LUQ tenderness on palpation. Skin: No rash.

#1: Infectious mononucleosis History Finding(s): -Sore throat for 2 weeks -LUQ pain -Recent history of ill contact Physical Exam Finding(s): -LUQ tenderness -Lymphadenopathy #2: Acute HIV infection History Finding(s): -Sore throat for 2 weeks -Two sexual partners over past year, active with men and women -Treated for gonorrhea 4 months a #3: Streptococcal pharyngitis History Finding(s): -Sore throat for 2 weeks -Low-grade fever -History of cigarette smoking Physical Exam Finding(s): -Lymphadenopathy

Physical Examination Patient is in no acute distress, looks tired with a flat affect, speaks and moves slowly. VS: WNL. HEENT: No conjunctival pallor, mouth and pharynx WNL. Neck: No lymphadenopathy, thyroid normal. Chest: Clear breath sounds bilaterally. Heart: RRR; normal S1/S2; no murmurs, rubs, or gallops. Abdomen: Soft, nondistended, nontender, BS, no hepatosplenomegaly. Extremities: No edema, normal DTRs in lower extrem

#1: Major depressive disorder History Finding(s): -Dysphoria, anhedonia -Loss of appetite -Passive suicidal ideation -Decreased energy/fatigue -Impaired concentration - Early awakening #2: Hypothyroidism History Finding(s): -Fatigue for 3 months -Cold intolerance -Hair loss -Weight gain #3: Posttraumatic stress disorder History Finding(s): -Nightmares about the trauma -Negative mood/anhedonia -Decreased concentration -Difficulty staying asleep

Physical Examination Patient is in no acute distress. VS: WNL. HEENT: No funduscopic abnormalities. Neck: No carotid bruits, no JVD. Chest: Clear breath sounds bilaterally. Heart: Apical impulse not displaced; RRR; normal S1/S2; no murmurs, rubs, or gallops. Abdomen: Soft, nondistended, nontender, BS, no bruits, no organomegaly. Extremities: No edema, no hair loss or skin changes. Radial, brachial, femoral, dorsalis pedis, and posterior tibialis 2+ and symmetric. Neuro: Motor: Strength 5/5 in bilateral lower extremities. Sensation: Intact to pinprick and soft touch in lower extremities. DTRs: Symmetric 2+ in lower extremities, Babinski bilaterally.

#1: Medication-induced erectile dysfunction History Finding(s): -Taking propranolol -Onset of ED coincides with propranolol use -No early-morning or nocturnal tumescence #2: Erectile dysfunction secondary to vascular disease History Finding(s): -History of hypertension -History of hyperlipidemia -No early-morning or nocturnal tumescence #3: Hypogonadism History Finding(s): -Loss of libido and ED -Hair loss -No early-morning or -nocturnal tumescence

Physical Examination Patient is in no acute distress. VS: WNL, no orthostatic changes. HEENT: NC/AT, PERRLA, EOMI without nystagmus, no papilledema, no cerumen, TMs normal, mouth and oropharynx normal. Heart: RRR; normal S1/S2; no murmurs, rubs, or gallops. Neuro: Cranial nerves: 2-12 grossly intact except for decreased hearing acuity in the left ear. Rinne (air conduction > bone conduction on the left), Weber no lateralization, tilt test. Motor: Strength 5/5 throughout. DTRs: 2+ intact, symmetric, Babinski bilaterally. Cerebellar: Romberg, finger to nose normal. Gait: Normal.

#1: Ménière's disease History Finding(s): Sensation of room spinning Left-sided hearing loss Physical Exam Finding(s): Decreased hearing acuity on the left Positive Rinne test #2: Benign paroxysmal positional vertigo History Finding(s): Sensation of room spinning Onset with positional changes Duration 20−30 minutes #3: Orthostatic hypotension causing dizziness History Finding(s): History of diarrhea Taking antihypertensive medication

Physical Examination Patient seems anxious and in mild distress. VS: HR 110, BP 140/80 HEENT: Pupils dilated, vertical gaze nystagmus. Chest: Clear breath sounds bilaterally. Heart: Tachycardic; normal S1/S2; no murmurs, rubs, or gallops. Abdomen: Soft, nontender, nondistended, no hepatosplenomegaly. Neuro: Mental status: Alert and oriented × 3, spells backward and recalls 3 objects. Cranial nerves: 2-12 intact. Motor: Strength 5/5 in all muscle groups. DTRs: Symmetric. Gait: Normal.

#1: PCP intoxication History Finding(s): -Drug use 1 day before presentation -Visual hallucinations -Noncommand auditory hallucinations -Delusion Physical Exam Finding(s): -Tachycardia (HR 110/minute) -Hypertension (BP 140/80) -Vertical gaze nystagmus #2: Substance-induced psychosis History Finding(s): -Drug use 1 day before presentation -Visual hallucinations -Noncommand auditory hallucinations -Delusions -No history of non-drug-related psychosis -Does not associate drug use with presentation Physical Exam Finding(s): -Pupils dilated

Physical Examination Patient is in no acute distress, looks sad. VS: WNL. HEENT: No conjunctival pallor, mouth and pharynx normal. Neck: Supple, no JVD, no lymphadenopathy, thyroid normal. Chest: Clear breath sounds bilaterally. Heart: RRR; normal S1/S2; no murmurs, rubs, or gallops. Abdomen: Soft, nondistended, mild epigastric tenderness, no rebound tenderness, Murphy's sign, BS, no hepatosplenomegaly. Extremities: No edema.

#1: Pancreatic cancer History Finding(s): -History of smoking and eating foods that are high in fat content -Unintentional weight loss of 8 lbs over past 6 months -Foul-smelling, greasy-looking stosis Physical Exam Finding(s):Mild epigastric tenderness #2: Depression History Finding(s): -Feelings of sadness -Loss of interest in activities; -early awakening; impaired concentration; low energy -Decreased appetite and unintentional weight loss #3: Chronic pancreatitis History Finding(s): History of alcohol use -Worsening epigastric discomfort that radiates to the back -Foul-smelling, greasy-looking stools Physical Exam Finding(s): -Mild epigastric tenderness

Physical Examination Patient is in no acute distress. VS: WNL. Chest: Clear breath sounds bilaterally. Heart: RRR; normal S1/S2; no murmurs, rubs, or gallops. Neuro: Mental status: Alert and oriented × 3. Cranial nerves: 2-12 grossly intact. Motor: Right hand resting tremor with "pill-rolling" movement that improves or disappears during purposeful action or posture. Mild muscle rigidity in both wrists and arms, but no frank cogwheeling. Strength 5/5 throughout. DTRs: Symmetric 2+ in all extremities. Cerebellar: Romberg, rapid alternating movements and heel-to-shin test normal and symmetric. Gait: Bradykinetic, takes small steps. Walks with back slightly bent forward. Sensation: Intact to soft touch and pinprick.

#1: Parkinson's disease History Finding(s) -Resting tremor Physical Exam Finding(s) -Low-frequency tremor in upper extremity -Bradykinetic gait -Upper extremity rigidity #2: Essential tremor History Finding(s) -Possible family history of tremor Physical Exam Finding(s) - Tremor in distal upper extremity #3: Physiologic tremor History Finding(s) -Resting tremor Physical Exam Finding(s) -Tremor in distal upper extremity

Physical Examination None.

#1: Physiologic jaundice History Finding(s): -Infant in first week of life - No changes in feeding, urination, or bowel movements #2: ABO or Rh incompatibility History Finding(s): - Infant in first week of life - Mother and father with different ABO types #3: Neonatal sepsis History Finding(s): - History of maternal infection

Physical Examination Patient is pleasant and in no acute distress. VS: WNL. Chest: Clear to auscultation bilaterally. Heart: RRR; normal S1/S2; no murmurs, rubs, or gallops. Abdomen: Soft, nontender, nondistended, BS. Extremities: Posterior tibialis and dorsalis pedis pulses 2+ bilaterally; mild bilateral rear/midfoot pronation; range of motion of hip/knee/ankle and foot WNL. Tender to palpation over medial calcaneal tuberosity and plantar fascia; plantar heel and arch pain with dorsiflexion of toes. Neuro: Motor: Strength 5/5 in hip/knee/ankle and foot. Sensation: Intact to light tough in saphenous, sural, and deep/superficial peroneal nerve distributions (dermatomes L4−S1). DTRs: 1+ in Achilles tendon. Gait: Non-antalgic gait pattern.

#1: Plantar fasciitis History Finding(s): -Training for a marathon -Pain is gradual -Pain worsens with first few steps in morning and after prolonged sitting Physical Exam Finding(s): -Tenderness over medial calcaneal tuberosity -Pain with toe dorsiflexion #2: Calcaneal stress fracture History Finding(s): -Training for a marathon -Diffuse pain over heel -Refractory to conservative management Physical Exam: Finding(s):Tenderness over plantar heel and arch #3: Achilles tendinitis History Finding(s): -Training for a marathon Physical Exam Finding(s): -Pain with toe dorsiflexion

Physical Examination Patient is in no acute distress. VS: WNL. HEENT: EOMI without diplopia or lid lag; visual fields full to confrontation. Neck: No thyromegaly. Chest: Clear breath sounds bilaterally. Heart: RRR; normal S1/S2; no murmurs, rubs, or gallops. Abdomen: Soft, nontender, nondistended, BS, no hepatosplenomegaly. Extremities: No edema, no tremor. Neuro: See HEENT. Normal DTRs in lower extremities bilaterally.

#1: Pregnancy History Finding(s): -Change in menstrual cycles - Regular sexual activity - Previous successful preg #2: Hyperprolactinemia History Finding(s): - Galactorrhea - Oligomenorrhea #3: Polycystic ovary syndrome History Finding(s): - Weight gain - Hirsutism - Oligomenorrhea

Physical Examination Patient is in no acute distress. VS: WNL. HEENT: NC/AT, PERRLA, EOMI, no nystagmus, no papilledema, no cerumen. TMs with light reflex, no stigmata of infection, no redness to ear canal, no tenderness of auricle or periauricle, no lymphadenopathy, oropharynx normal. Weber test without lateralization; Rinne test (revealed air conduction > bone conduction). Chest: Clear breath sounds bilaterally. Heart: RRR; S1/S2; no murmurs, rubs, or gallops. Neuro: Cranial nerves: 2-12 grossly intact except for decreased hearing. Motor: Strength 5/5 throughout. DTRs: 2+ throughout. Sensation: Intact. Gait: Normal; no past pointing and (- )heel to shin.

#1: Presbycusis >History Finding(s): - Bilateral, progressive hearing loss -Advanced age - Hypertension >Physical Exam Finding(s): - Positive Rinne test - Lack of lateralization on Weber test #2: Cochlear nerve damage >History Finding(s): - Prior exposure to loud noise - Bilateral hearing loss >Physical Exam Finding(s): - Positive Rinne test - Lack of lateralization on Weber test #3: Otosclerosis >History Finding(s): - Bilateral, progressive hearing loss - Advanced age >Physical Exam Finding(s): - Lack of lateralization on Weber test

Physical Examination Patient is in no acute distress. VS: WNL. HEENT: Mouth and pharynx WNL. Neck: No JVD, no lymphadenopathy. Chest: Clear breath sounds bilaterally; no rhonchi, rales, or wheezing; tactile fremitus normal. Heart: Apical impulse not displaced; RRR; normal S1/S2; no murmurs, rubs, or gallops. Abdomen: Soft, nontender, BS, no hepatosplenomegaly. Extremities: No clubbing, cyanosis, or edema.

#1: Pulmonary tuberculosis History Finding(s): -Fever and night sweats with fatigue; worsening cough of 1 month's duration -Close contact with patients with active TB -Decreased appetite with unintentional weight loss of 6 lbs over 2 months Physical Exam Finding(s): Blood-tinged mucus #2: Lung cancer History Finding(s): -Fever and night sweats with fatigue -Decreased appetite with unintentional weight loss of 6 lbs over 2 months -History of heavy smoking and chronic bronchitis Physical Exam Finding(s): -Blood-tinged mucus #3: Typical pneumonia History Finding(s): -Fever -Mucus production -History of heavy smoking and chronic bronchitis Physical Exam Finding(s):Sputum production

Physical Examination None.

#1: Simple febrile seizure History Finding(s) -Seizure duration < 15 minutes -No prior history of seizures -Fever (Tmax 102.9°F) #2: Meningitis History Finding(s) -Tonic-clonic seizure -Fever (Tmax 102.9°F) -Decreased appetite -Decreased urine output #3: Hyponatremia History Finding(s) -Seizure

Physical Examination None.

#1: Viral URI > History Finding(s): Fever (101°F) Rhinorrhea Sibling with URI Day care attendance Increased breathing rate #2: Pneumonia History Finding(s): Fever (101°F) Day care attendance Sibling with URI Increased breathing rate #3: Otitis media History Finding(s): -Fever (101°F) -Irritability -Day care attendance

Physical Examination None.

#1: Viral URI History Finding(s): -Fever (101°F) -Rhinorrhea -Sibling with URI -Day care attendance Increased breathing rate #2: Pneumonia History Finding(s): -Fever (101°F) -Day care attendance -Sibling with URI -Increased breathing rate #3: Otitis media History Finding(s): -Fever (101°F) -Irritability -Day care attendance

Physical Examination None.

#1: Viral gastroenteritis History Finding(s) -Acute watery diarrhea -Low-grade fever (100.5°F) -Day care attendance #2: Bacterial diarrhea History Finding(s) -Acute diarrhea -Day care attendance -Low-grade fever (100.5°F) #3: Malabsorption History Finding(s) -Watery diarrhea - Dry mouth

Physical Examination Patient is in no acute distress. VS: WNL. Chest: Clear breath sounds bilaterally. Heart: RRR; normal S1/S2; no murmurs, rubs, or gallops.

#1: Vulvovaginitis History Finding(s): - White vaginal discharge - Fishy odor of discharge - Vaginal pruritus #2: Cervicitis History Finding(s): -White vaginal discharge -Dyspareunia -Sexual activity without barrier contrac #3: Endometriosis History Finding(s): -Dysmenorrhea -Dyspareunia

C 7/ Richard Green, a 74-year-old male, comes to the ED complaining of pain in his right arm. Vital Signs BP: 135/85 mm Hg Temp: 98.0°F (36.7°C) RR: 12/minute HR: 76/minute, regular --------------- - XR—right shoulder and arm - MRI—shoulder - Bone density scan (DEXA)

==> History - HPI: 74 yo M c/o right arm pain for the past 3 days. The pain started after he fell on his outstretched right arm and persisted despite his use of Tylenol and a sling at home. No loss of consciousness before or after the fall. No paralysis or loss of sensation. The pain is in the upper and middle part of the arm, increases with any movement of the arm, and is alleviated by rest. When asked why he delayed seeking medical assistance, the patient looked anxious and stated that his son didn't have time to take him to the hospital. - ROS: Negative except as above. - Allergies: Aspirin (rash). -Medications: Tylenol, albuterol inhaler. - PMH: Asthma, probable BPH s/p prostate surgery. PSH: As above. - SH: No smoking, no EtOH. Widower for the past 3 years; lives with his son, who recently lost his job. Walks 20 minutes every morning.

C9/ Julia Melton, a 25-year-old female, comes to the ED after being assaulted. Vital Signs BP: 120/85 mm Hg Temp: 98.0°F (36.7°C) RR: 17/minute HR: 90/minute, regular ---------------- - Pelvic exam - XR—skeletal survey - CXR - Urine hCG - Wet mount, KOH prep, cervical culture, gonorrhea and chlamydia tests - HIV antibody, VDRL, HBV antigen

==> History - HPI: 25 yo F comes to the ED after being sexually and physically assaulted. The event happened about 3 hours ago as she was leaving a bar. She was beaten and raped by 2 unknown men. They had vaginal intercourse with her without using condoms, and she is unsure if ejaculation occurred. Her LMP was 3 weeks ago. She does not use any form of contraception. She also c/o shortness of breath, palpitations, and right chest pain that is nonradiating. The chest pain is exacerbated by movement and deep breaths and is relieved by sitting still. No nausea or vomiting. No dizziness or headache. No weakness or numbness in her extremities; no vaginal, rectal, or urinary bleeding. - ROS: Negative except as above. - Allergies: NKDA. - Medications: None. - PMH: None. - PSH: None. - SH: No smoking, occasional EtOH, no illicit drugs. FH: Noncontributory.

C8/ Raymond Stern, a 56-year-old male, comes to the clinic for diabetes follow-up. Vital Signs BP: 139/85 mm Hg Temp: 98.0°F (36.7°C) RR: 15/minute HR: 75/minute, regular ------------- -Genital exam -Serum glucose, HbA1c -UA, urine microalbumin, -BUN/Cr -Doppler U/S—penis -Nerve conduction

==>History -HPI: 56 yo M presents for diabetes follow-up. 25-year history of DM, treated with insulin. Compliant with medications. Monitors blood glucose twice a week, readings between 120 and 145 mg/dL. Last HbA1c 6 months ago was 7%. Occasional episodes of palpitations and diaphoresis, occurring after missing meals and resolving with drinking orange juice. Tingling and numbness in feet all the time, especially at night, worse over past 2 months. Loss of erections × 2 years; absence of early-morning erections. No weight or appetite changes. No special diet. - ROS: Negative except as above. - Allergies: NKDA. - Medications: Lovastatin, NPH insulin, aspirin, atenolol. - PMH: Hypercholesterolemia diagnosed 2 years ago; MI 1 year ago. - PSH: None. - SH: No smoking, drinks whiskey on weekends (CAGE 0/4), no illicit drugs. Works as a clerk. He is married and lives with his wife. - FH: Father died of a stroke at age 60.

C5/ Tanya Parker, a 28-year-old female, comes to the clinic with a positive pregnancy test. Vital Signs BP: 120/70 mm Hg Temp: 98.6°F (37°C) RR: 14/minute HR: 76/minute -- - Urine hCG - U/S—pelvis - Breast/pelvic exams - Blood type, Rh, antibody screen

==>History - HPI: 28 yo G0 presents with a positive pregnancy test. Her LMP was 6 weeks ago and was unusually scant. She reports bilateral breast engorgement, poor appetite, nausea with no vomiting, increased urinary frequency, and feeling bloated and fatigued. She is sexually active with her husband only, with coitus interruptus as the only method of contraception. This is an unplanned pregnancy, and she is unsure whether she will continue. - OB/GYN: G0, menarche at age 14, has regular periods 4-5/30. No history of STDs; last Pap smear was taken 8 months ago and was normal. - ROS: Denies abnormal bleeding, abdominal pain, fever, shortness of breath, or change in bowel habits. -Allergies: NKDA. -Medications: Multivitamins. - PMH: None. - PSH: Appendectomy at age 20. - SH: No smoking, 1-2 beers/week, no illicit drugs. Married graduate student; denies domestic violence. - FH: Father is a diabetic. Mother has thyroid problems and obesity.

C6/ The mother of Louise Johnson, a 10-year-old female child, comes to the office because she is concerned that her daughter was recently diagnosed with diabetes. Examinee Tasks 1. Take a focused history. 2. Explain your clinical impression and workup plan to the mother. 3. Write the patient note after leaving the room -------------------------- - Insulin and C-peptide levels - Islet cell antibodies - HbA1c - Electrolytes, glucose - UA and urine microalbumin - 24-hour urine free cortisol

==>History: - HPI: The source of the information is the patient's mother. The mother of a 10 yo F states that her child was diagnosed with DM 1 month ago, when she presented with excessive thirst and frequent urination. The parents were shocked after the diagnosis was made. The child seems concerned but not irritable or depressed. She is active, plays tennis, and is currently on a diet prescribed by a dietitian. She is on insulin injections and regularly monitors her blood glucose levels at home. Her compliance is good; she checks her blood glucose before each meal and at bedtime. Fasting glucose levels are usually 80 to the low 100s and in the high 100s before meals. She has not had any episodes of hypoglycemia. She has lost 9 lbs in the past 3 months, but her weight is stable now at about 180 lbs. She denies any weakness, fatigue, tingling over the limbs, visual symptoms, or rash/itch at the injection sites. She has not yet started menstruating. - ROS: Negative. -Allergies: NKDA. - Medications: Insulin. PMH: None. - PSH: None. - Birth history: Normal. - Developmental history: Normal. - FH: No family history of diabetes.

C2/ Carl Fisher, a 57-year-old male, comes to the ED complaining of bloody urine. Vital Signs BP: 130/80 mm Hg Temp: 98.5°F (36.9°C) RR: 13/minute HR: 72/minute, regular ================= Genital exam Rectal exam Cystoscopy U/S—renal UA CT—abdomen/pelvis PSA

=> HPI: 57 yo male c/o 1 episode of painless hematuria yesterday morning. He has no fever, no abdominal or flank pain, and no dysuria. No history of renal stones. He has a 2-year history of straining on urination, polyuria, nocturia, weak urinary stream, and dribbling. No nausea, vomiting, diarrhea, or constipation. No change in appetite or weight loss. No previous similar episodes. ROS: Negative except as above. => Allergies: NKDA. => Medications: Allopurinol. => PMH: Gout. => PSH: Appendectomy, age 23. => SH: 1 PPD for 30 years, 2 beers 2-3 times/week, no illicit drugs. Works as a painter. Heterosexual, has a partner, and uses condoms regularly. => FH: Father died from kidney disease at age 80.

C1/ Joseph Short, a 46-year-old male, comes to the ED complaining of chest pain. Vital Signs BP: 165/85 mm Hg Temp: 98.6°F (37°C) RR: 22/minute HR: 90/minute, regular - ECG - Cardiac enzymes (CPK, CPK-MB, troponin) - Transthoracic echocardiography - Upper endoscopy - Urine toxicology

>> HPI: 46 yo M c/o substernal chest pain. The pain started 40 minutes before the patient presented to the ED. The pain woke the patient from sleep at 5:00 A.M. with a steady 7/10 pressure sensation in the middle of his chest that radiated to the left arm, upper back, and neck. Nothing makes it worse or better. Nausea, sweating, and dyspnea are also present. Similar episodes have occurred during the past 3 months, 2-3 times/week. These episodes were precipitated by walking up the stairs, strenuous work, sexual intercourse, and heavy meals. Pain during these episodes was less severe, lasted for 5-10 minutes, and disappeared spontaneously or after taking antacids. >>ROS: Negative except as above. >>Allergies:NKDA. >>Medications:Maalox, diuretic. >>PMH: Hypertension for 5 years, treated with a diuretic. High cholesterol, managed with diet. GERD 10 years ago, treated with antacids. >>SH: 1 PPD for 25 years; stopped 3 months ago. Occasional EtOH, occasional cocaine for 10 years (last used yesterday afternoon). No regular exercise; poorly adherent to diet. >>FH: Father died of lung cancer at age 72. Mother has peptic ulcers. No early coronary disease.

Physical Examination Patient is in severe pain. VS: WNL except for low-grade fever. Chest: Clear breath sounds bilaterally; no rales or rhonchi. Heart: RRR; normal S1/S2; no murmurs, rubs, or gallops. Abdomen: Soft, nontender, nondistended, BS. Extremities: Inspection: Right calf appears red and swollen compared to left; contours of the muscles appear normal; no ulcers or pigmentation. Palpation: Right leg is warmer compared to left; pitting pedal edema on right side; multiple healing cuts covered with bandage on right leg; dorsalis pedis pulse felt and equal on both sides; mobility normal at ankle joint, knee, and hip joint; Homans' sign on right side. Neuro: Mental status: Alert and oriented. DTRs: Symmetric 2+. Motor/sensation: Normal. Cranial nerves: 2-12 intact. Gait: Normal.

Diagnosis #1: -Deep venous thrombosis History Finding(s) -Recent 15-hour airplane flight -Weight gain of 50 lbs over past 3 years -Taking OCPs for 2 years -Father with DVT (possible familial thrombophilia) Physical Exam Finding(s) - Homans' sign -Pitting edema -Swollen, tender, red, warm right calf Diagnosis #2: Cellulitis History Finding(s) -Cuts to right leg secondary to fall -Low-grade feverSwollen, Physical Exam Finding(s): - tender, red, warm right calf Temperature 99.9°F Diagnosis #3: Rupture of Baker's cyst History Finding(s) -Spasmodic pain in right calf Physical Exam Finding(s) -Swollen, tender, warm right calf

Physical Examination Patient sitting rigid and still, avoiding moving neck. VS: WNL. Neck: No scars or deformities, limited ROM 2/2 pain. Tenderness to palpation on cervical spinous processes. Lhermitte and Spurling tests. Extremities: No scars or deformities, brachial and radial pulses full. Full range of motion. Neuro: Motor: Strength 5/5 throughout upper extremities. DTRs: 2+ symmetric, Babinski bilaterally. Sensation: Loss of pinprick sensation noted on dorsum of left hand and posterior left arm and forearm; all other sensation normal.

Diagnosis #1: Disk herniation History Finding(s) - Neck pain that increases with movement - Radiculopathy (left arm numbness) Physical Exam Finding(s): - Loss of pinprick sensation noted on dorsum of left hand and posterior left arm and forearm Diagnosis #2: Cervical fracture History Finding(s) -Rapid rotation of neck preceded pain -Pain increases with movement - Osteopenia on last DEXA Diagnosis #3: Neck muscle strain History Finding(s) -Rapid rotation of neck preceded pain

Physical Examination Patient is in no acute distress. VS: WNL except for low-grade fever. HEENT: Nose, mouth, and pharynx WNL. Neck: Right anterior cervical chain with lymphadenopathy. No lymphadenopathy on the left. Chest: Nontender, bilateral clear BS. Heart: PMI not displaced, regular rhythm, no murmurs or rubs. Abdomen: BS, nondistended, no organomegaly. Extremities: DTRs are equal.

Diagnosis #1: Laryngeal cancer =>History Findings(s) - Cervical lymphadenopathy - Worsening hoarseness over past 3 months - Weight loss, decreased appetite, and low-grade fever - History of cigarette smoking and alcohol use - Advanced age =>Physical Exam Finding(s) - Temperature 99.9°F Diagnosis #2: Laryngitis History Finding(s) - History of flu 4 weeks ago - Low-grade fever - GERD - History of cigarette - smoking => Physical Exam Finding(s) -Temperature 99.9°F Diagnosis #3: Vocal cord polyp/nodule History Finding(s) -Vocal overuse from teaching for 20 years

19/ The mother of Josh White, a 7-month-old male child, comes to the office complaining that her child has a fever. Examinee Tasks 1. Take a focused history. 2. Explain your clinical impression and workup plan to the mother. 3. Write the patient note after leaving the room.

HPI: History obtained from mother. The patient is a 7-month-old M with fever × 1 day. Temperature recorded by forehead thermometer at home reached 101°F yesterday. The child has been tired, irritated, and breathing rapidly for the past day. The mother denies any abdominal retractions or nasal flaring. The mother also notes rhinorrhea and refusal of breast and baby food. The child has a history of sick contact with his 3 yo brother, who had a URI 1 week ago that has since resolved. He attends day care. No cough, ear pulling, ear discharge, or rash. ROS: Negative except as above. Allergies: NKDA. Medications: Tylenol. PMH: Jaundice in the first week of life. PSH: None. Birth history: 40-week vaginal delivery with no complications. Dietary history: Breast-feeding and supplemental vitamins. Immunization history: UTD. Developmental history: Last checkup was 2 weeks ago and showed normal weight, height, and develop- mental milestones.

C20/ Eric Glenn, a 26-year-old male, comes to the office complaining of cough. Vital Signs BP: 120/80 mm Hg Temp: 99.9°F (37.7°C) RR: 15/minute HR: 75/minute, regular

History HPI: 26 yo M c/o cough × 1 week. # 2 weeks ago: fever, rhinorrhea, sore throat. # Persistent productive cough with small amount of white mucus but no hemoptysis. # Sharp, stabbing 8/10 pain in right chest, exacerbated by cough and deep inspiration. # Mild fever. # Denies chills, night sweats, SOB, or wheezing. # No recent travel. # No TB exposure. # No weight or appetite changes. - ROS: Negative except as above. - Allergies: NKDA. - Medications: Tylenol. - PMH: Gonorrhea 2 years ago, treated with antibiotics. - SH: 1 PPD since age 15; drinks heavily on weekends. CAGE 0/4. Unprotected sex with multiple female partners. - FH: Noncontributory.

C25 The mother of Maria Sterling, an 18-month-old female child, comes to the office complaining that her child has a fever. Examinee Tasks 1. Take a focused history. 2. Explain your clinical impression and workup plan to the mother. 3. Write the patient note after leaving the room.

History HPI: History obtained from mother. Patient is 18-month-old F with fever × 2 days. #Temperature recorded at home, 101°F. #Tired and not playing with toys or watching TV as usual. #Pulling at right ear. #Difficulty swallowing and sleeping × 2 days. #Loss of appetite. #One episode of vomiting. #Maculopapular facial rash that spread over the chest, back, and abdomen, sparing the arms and legs. #Attends day care center, no known history of sick contacts. #No ear discharge. #History of cough and runny nose for a few days last week. ROS: Negative except as above. Allergies: NKDA. Medications: Tylenol. PMH: Otitis media 3 months ago, treated with amoxicillin. Birth history: 40-week vaginal delivery with no complications. Dietary history: Formula milk and solid food. She was not breast-fed. Immunization history: UTD. Developmental history: Last checkup was 1 month ago and showed normal weight, height, hearing, vision, and developmental milestones.

C42/ The mother of Michaela Weber, an 11-month-old female child, comes to the emergency department after her daughter has a seizure. Examinee Tasks 1. Take a focused history. 2. Explain your clinical impression and workup plan to the mother. 3. Write the patient note after leaving the room.

History HPI: The source of information is the patient's mother. Patient is an 11-month-old F with a tonic-clonic seizure. #Witnessed this A.M. by parents, lasted approx. 1 minute. #No tongue or body trauma. #Postictal drowsiness noted. #No history of prior seizures. #Patient has had rhinorrhea for past 2 days, fevers to 102.9°F with decreased PO intake, difficulty sleeping, and fewer wet diapers. #No rash, nausea/vomiting, lethargy, or inconsolability. #No sick contacts. ROS: Negative except as above. Allergies: NKDA. Medications: Tylenol. PMH/PSH: None. Birth history: Term uncomplicated vaginal delivery. Dietary history: Breast milk, table foods, and supplemental vitamins. Immunization history: Up to date. Developmental history: Last checkup was 2 months ago and showed normal weight, height, and development.

C13/Sharon Smith, a 48-year-old female, comes to the clinic complaining of abdominal pain. Vital Signs BP: 135/70 mm Hg Temp: 98.5°F (36.9°C) RR: 16/minute HR: 76/minute, regular ===================== Diagnostic Workup Rectal exam, stool for occult blood U/S—abdomen Upper endoscopy H pylori antibody testing

History - HPI: 48 yo F c/o intermittent, burning, nonradiating epigastric pain that started for the first time 2 weeks ago. The pain occurs at least once a day, usually 2-3 hours after meals. It is exacerbated by hunger and heavy, fatty foods and is alleviated by milk, antacids, and other food. It reaches 7/10 in severity and then diminishes to 0/10. It is sometimes accompanied by nausea. The patient vomited once yesterday: a sour, yellowish, nonbloody fluid. No diarrhea or constipation. No changes in weight or appetite. No changes in the color of the stool. - ROS: Negative except as above. - Allergies: NKDA. Medications: Maalox, ibuprofen. - PMH: Arthritis in the knees, treated with ibuprofen. UTI last year, treated with amoxicillin. - - - PSH: 2 C-sections. - SH: No smoking, no EtOH, no illicit drugs. Sexually active with husband only. FH: Father died of pancreatic cancer at age 55.

29/ Opening Scenario Gwen Potter, a 20-year-old female, comes to the clinic complaining of sleeping problems. Vital Signs BP: 120/80 mm Hg Temp: 98.6°F (37°C) RR: 18/minute HR: 102/minut

History HPI: 20 yo F college student c/o inability to sleep. She has difficulty falling asleep until 2 A.M. and also has difficulty staying asleep. She used to get 8 hours of sleep, but for the past month she has been getting a total of only 4 hours per night. She has difficulty getting up after hearing the alarm and feels tired while at school. She notes inability to concentrate during classes and while driving. The patient appears to be stressed about her coursework and about her performance at school. She has also been snoring for the past few months and has had palpitations, especially after drinking caffeine. She has a history of drinking 4-5 cups of coffee per day. She has lost weight (6 lbs in 1 month) and has sweaty palms. There is an increase in the frequency of her bowel movements. She lives with her boyfriend, and they use condoms and OCPs for contraception. There is no history of sexual abuse, recent infection, or recent tragic events in her life. ROS: Negative except as above. Allergies: NKDA. Medications: Multivitamins, OCPs. PMH: None. PSH: Tonsillectomy at age 12. SH: No smoking, 1-2 beers/week, no illicit drugs. FH: Not significant.

31/ Jessica Anderson, a 21-year-old female, comes to the ED complaining of abdominal pain. Vital Signs BP: 120/80 mm Hg Temp: 100.5°F (38.1°C) RR: 20/minute HR: 88/minute, regular

History HPI: 21 yo G1P1 F c/o right lower abdominal pain that started this morning. The pain is 7/10, crampy, nonradiating, and constant. It is exacerbated by movement and accompanied by fever, nausea, vomiting, and loose stools. The patient noticed some brownish spotting this morning. No urinary symptoms; no abnormal vaginal discharge. OB/GYN: LMP 5 weeks ago. Regular periods every 4 weeks lasting 7 days. Menarche at age 13. Uncomplicated NSVD at full term 3 years ago. ROS: Negative except as above. Allergies: NKDA. Medications: Ibuprofen. PMH: STD 1 month ago, possibly treated with ceftriaxone and doxycycline. PSH: None. SH: 1 PPD for 6 years, 2-3 beers/week, no illicit drugs. Unprotected sex with multiple partners over the past year.

C43 Brian Davis, a 21-year-old male, comes to the office complaining of a sore throat. Vital Signs BP: 120/80 mm Hg Temp: 99.5°F (37.5°C) RR: 15/minute HR: 75/minute, regular

History HPI: 21 yo M c/o sore throat for the past 2 weeks. Two weeks ago he had a mild fever and fatigue, but he denies any chills, runny nose, cough, night sweats, shortness of breath, or wheezing. The patient also notes LUQ abdominal pain since yesterday. The pain is 4/10 and constant with no radiation, no relation to food, and no alleviating or exacerbating factors. He has poor appetite and subjective weight loss. His ex- girlfriend had the same symptoms 2 months ago. ROS: Negative except as above. Allergies: NKDA. Medications: Tylenol. PMH: Gonorrhea 4 months ago, treated with antibiotics. PSH: None. SH: 1 PPD since age 15; drinks heavily on weekends. Multiple female and male partners; uses condoms. FH: Noncontributory.

C4/ John Matthews, a 25-year-old male, comes to the ED following a motor vehicle accident. Vital Signs BP: 123/88 mm Hg Temp: 100°F (38°C) RR: 22/minute HR: 85/minute, regular - CXR - Sputum and blood Gram stain and culture

History HPI: 25 yo M c/o left chest pain and LUQ pain following an MVA. The patient struck a tree with his car at a slow speed. The chest pain is 8/10. It is exacerbated with movement or when he takes a deep breath, and nothing relieves it. He reports dyspnea and a productive cough with a low-grade fever but denies LOC, headache, change in mental status, or change in vision. No cardiovascular or neurologic symptoms. No nausea, vomiting, neck stiffness, or unusual fluid from the mouth or nose. No dysuria. His last meal was 5 hours ago. He denies being under the influence of alcohol or drugs. ROS: As per HPI. Allergies: NKDA. Medications: None. PMH: Infectious mononucleosis. PSH: None. SH: No smoking, occasional EtOH, no illicit drugs. FH: Noncontributory.

35/ Jack Edwards, a 27-year-old male, comes to the ED complaining of seeing strange writing on the wall.

History HPI: 27 yo M c/o episodes of seeing strange writing on the wall since yesterday. These episodes last less than a minute and have happened 3-4 times. The patient states that the writing is not clear and he cannot read the messages, but he thinks he might be getting instructions from them. He denies any other visual changes or visual loss. The patient also mentions hearing strange voices associated with the writing, adding that he cannot understand them either. He admits to having used illicit drugs 1 day before these events. He denies any headache, seizures, head trauma, or previous similar episodes. No appetite or weight changes, fever, or sleep problems. ROS: Negative except as above. Allergies: NKDA. Medications: None. PMH: None. PSH: None. SH: 1 PPD for 6 years; uses PCP ("angel dust") and MDMA (Ecstasy) occasionally; no EtOH. Works as a bartender. FH: Noncontributory

C16/ Stephanie McCall, a 28-year-old female, comes to the office complaining of pain during sex. Vital Signs BP: 120/85 mm Hg Temp: 98.0°F (36.7°C) RR: 13/minute HR: 65/minute, regular

History HPI: 28 yo F c/o pain during intercourse for 3 months, located both superficially and with deep thrusting. She also noticed a scant white vaginal discharge with a fishy odor, accompanied by mild vaginal pruritus. She denies postcoital or intermenstrual vaginal bleeding. She is sexually active with her boyfriend (only) for the past year, and her sexual desire is normal. She feels safe at home and denies any conflicts with her partner. She also denies vaginal dryness, hot flashes, hirsutism, depression, fatigue, sleep problems, dysuria, and urinary frequency. OB/GYN: G0P0. Last menstrual period 2 weeks ago; has regular menses but started to be painful over the past year. No history of abnormal Pap smears; most recent was 6 months ago. Uses patch for contraception. ROS: Negative except as above. Allergies: NKDA. Medications: None. PMH: History of rape 10 years ago; subsequently contracted gonorrhea. PSH: None. SH: No tobacco. Drinks a couple of beers on the weekends, occasional wine, CAGE 0/4; used marijuana in college. Exercises regularly. FH: Noncontributory.

39/ Kristin Grant, a 30-year-old female, comes to the office complaining of weight gain. Vital Signs BP: 120/85 mm Hg Temp: 98.0°F (36.7°C) RR: 13/minute HR: 65/minute, regular BMI: 30

History HPI: 30 yo F c/o weight gain of 20 lbs over the past 3 months after she stopped smoking. She has a good appetite and reports no change in her diet. For 6 months she has experienced oligomenorrhea and hypomenorrhea, dry skin, and cold intolerance. The patient denies voice change, constipation, hirsutism, depression, fatigue, or sleep problems. OB/GYN: Last menstrual period last week. See HPI for other. ROS: Negative except as above. Allergies: NKDA. Medications: Lithium, started 6 months ago. PMH: Bipolar disorder, diagnosed 6 months ago. PSH: None. SH: 2 PPD for 10 years; stopped 3 months ago. No alcohol, no illicit drugs. Sexually active with husband only. Doesn't exercise. FH: Mother and sister are obese. Diet: Consists mainly of lots of coffee during the day, chicken, steak, and Chinese food.

C24/ Will Foreman, a 31-year-old male, comes to his primary care physician complaining of heel pain. Vital Signs BP: 125/80 mm Hg Temp: 99.0°F (37.2°C) RR: 14/minute HR: 69/minute, regular

History HPI: 31 yo M c/o pain on the plantar surface of his right heel. The pain started gradually about 2 weeks ago and has not progressed. The patient denies trauma or a specific inciting event but admits to training for a marathon. He describes the pain as intermittent and states that it is worse after getting out of bed in the morning and after prolonged sitting. He reports that the pain has a tearing/stretching quality and that it can get as high as 7/10. He has used ice, massage, and occasional ibuprofen for the pain, with limited relief. The patient denies any tingling, burning, or numbness. He denies proximally radiating symptoms but does report occasional pain radiating into his arch. ROS: Denies nausea/vomiting, weight/appetite changes, fever/chills, diarrhea/constipation, or fatigue. Allergies: NKDA. Medications: Occasional ibuprofen. PMH: None. Denies cancer, rheumatologic disorders, or diabetes. PSH: None. SH: No smoking, 1-2 beers/week, no illicit drugs. Works as an accountant; sexually active with wife of 10 years. Marathon runner. FH: Father with arthritis. Denies FH of cancer, rheumatologic disorders, or diabetes.

C34/ Jessica Lee, a 32-year-old female, comes to the office complaining of fatigue. Vital Signs BP: 120/85 mm Hg Temp: 98.2°F (36.8°C) RR: 13/minute HR: 80/minute, regula

History HPI: 32 yo F c/o fatigue and weakness × 5 months. #Fatigue increases throughout the day. #Loss of energy and concentration, which is affecting job as nurse. #Patient admits that husband, who is an alcoholic, has beaten her. #At least 1 episode of physical abuse directed at youngest son. #Patient attempts to defend husband's actions. #Feels guilty. #Self-blame. #Has not reported abuse. No head trauma or accidents due to husband. #No emergency plan. #Feels sad but denies suicidal ideation. #Polyuria, polydipsia, nocturia × 5 months. #LMP 2 weeks ago, menstrual period is regular, q28 days, lasting 7 days of heavy flow. #No dysuria or change in color of urine. #No constipation, cold intolerance, or change in appetite or weight. #No sleep problems. ROS: Negative except as above. Allergies: NKDA. Medications: None. PMH/PSH: None. SH: No smoking, no EtOH. Sexually active with her husband; decreased sexual desire. FH: Diabetic father died from a heart attack; mother is in a nursing home with Alzheimer's disease

C36/ Frank Emanuel, a 32-year-old male, comes to the office for a preemployment medical checkup as requested by his prospective employer.

History HPI: 32 yo M with no PMH presents for a preemployment medical examination. He has no medical complaints or problems. Nevertheless, he mentioned having a chronic cough for many years with no recent change in frequency or severity. The cough is productive of half a teaspoonful of white mucus with no blood. The patient denies any dyspnea, fever or chills, chest pain, or wheezing and has had no appetite or weight changes. The patient is an African immigrant who came to the United States 1 month ago and reports no TB exposure. He has never had a PPD test. However, he states that his immunizations are up to date, and he will be faxing us the report to review. ROS: Negative except as above. Allergies: NKDA. Medications: None. PMH: Per HPI. PSH: None. SH: 1 PPD for 10 years, no EtOH, no illicit drugs. Sexually active with wife only. FH: Noncontributory.

C23/ Kathleen Moore, a 33-year-old female, comes to the clinic complaining of knee pain. Vital Signs BP: 130/80 mm Hg Temp: 99.9°F (37.7°C) RR: 16/minute HR: 76/minute, regular

History HPI: 33 yo F c/o left knee pain that started 2 days ago and is causing difficulty walking. She has swelling and redness in her left knee and mild fever but no chills. She denies trauma. She has a history of fatigue and painful wrists and fingers and has experienced 1-hour morning stiffness over the past 6 months. She also recalls multiple oral ulcers that resolved last month. She describes Raynaud's phenomenon but denies rash, photosensitivity, hair loss, or recent tick bites. She recalls a 10-lb weight loss over the past 6 months and has no appetite. ROS: Negative except as above. Allergies: NKDA. Medications: Tylenol. PMH: Episode of acute left big toe arthritis 5 years ago; gonorrhea 1 year ago. PSH: Two C-sections, 2 spontaneous abortions. SH: 1 PPD for 20 years. Usually drinks 2-4 beers/week; on weekends drinks more; last ingestion 4 days ago; CAGE 0/4. No illicit drugs. Sexually active with multiple partners; inconsistent condom use. FH: Mother has rheumatoid arthritis and lives in a nursing home.

14/ Opening Scenario Kelly Clark, a 35-year-old female, comes to the ED complaining of headache. Vital Signs BP: 135/80 mm Hg Temp: 98.6°F (37°C) RR: 16/minute HR: 76/minute, regular ====== Diagnostic Workup CBC CT—head or MRI—brain LP CT—sinus

History HPI: 35 yo F c/o daily headaches for 2 weeks. These headaches occur 2-3 times a day and last for 1-2 hours. The pain is sharp and pounding. The pain is located on the right hemisphere of the head, with no radiation or preceding aura. The pain reaches 9/10 in severity and prevents the patient from continuing her activities. Headaches are exacerbated by stress, light, and noise and are alleviated by resting in a dark room, sleeping, and taking aspirin. The pain is sometimes accompanied by nausea and vomiting. No changes in weight or appetite. ROS: Occasional aches and pains. Allergies: NKDA. Medications: Ibuprofen, aspirin. PMH: Headaches at age 20, accompanied by nausea. One episode of sinusitis 4 months ago, treated with amoxicillin. PSH: Tubal ligation 8 years ago. SH: No smoking, no EtOH, no illicit drugs. Patient is an engineer, lives with husband and 3 children, and is sexually active with husband only. FH: Father died of a brain tumor at age 65. Mother has migraines.

C10/ Riva George, a 35-year-old female, comes to the hospital complaining of pain in her right calf. Vital Signs BP: 130/70 mm Hg Temp: 99.9°F (37.7°C) RR: 13/minute HR: 88/minute ----------- Diagnostic Workup: Doppler U/S—legs D-dimer Hypercoagulability testing CBC with differential Wound and blood cultures

History HPI: 35 yo F c/o right calf pain of a few days' duration. The pain is constant, 8/10 in intensity, not radiating, aggravated on walking and extending the knee, and associated with swelling, redness, and warmth. It is alleviated on elevation of the foot and with ibuprofen. The patient took a 15-hour flight 1 week ago. She has a history of weight gain postpartum and cuts to the right leg secondary to a fall. She has 2 children, both normal deliveries. LMP was 2 weeks ago. The patient says she has gained 50 lbs in the past 3 years. She has been on OCPs for 2 years. No history of chest pain or shortness of breath. ROS: Negative except as above. Allergies: NKDA. Medications: OCPs, ibuprofen. PMH: None. PSH: None. SH: No smoking, no EtOH, no illicit drugs. FH: Father had DVT. No history of sudden deaths in the family.

15/ Patricia Garrison, a 36-year-old female, comes to the office complaining of not having menstrual periods recently. Vital Signs BP: 120/85 mm Hg Temp: 98.0°F (36.7°C) RR: 13/minute HR: 65/minute, regular

History HPI: 36 yo F c/o amenorrhea for 3 months. She recently noticed some milky discharge from her left breast as well as abnormal facial hair but denies visual changes or headache. She also describes oligomenorrhea, hypomenorrhea, and a 15-lb weight gain over the past year but denies dry skin, cold intolerance, voice change, constipation, depression, fatigue, or sleep problems. She also denies hot flashes and vaginal dryness or itching. OB/GYN: Menarche at age 14. For the past year, menses have cycled every 5-6 weeks and lasted for 7 days, with decreased blood flow. Before that, menses cycled every 4 weeks. G1P1; 1 uncomplicated vaginal delivery 10 years ago. Last Pap smear 10 months ago; no history of abnormal Pap smears. Sexually active with husband once a week on average; uses OCPs for contraception. ROS: Negative except as above. Allergies: NKDA. Medications: None. PMH/PSH: None. SH: Denies tobacco, alcohol, or illicit drug use. Exercises regularly. Vegetarian; hasn't changed her diet recently. FH: Mother had menopause at age 55.

C33/ Opening Scenario Gary Mitchell, a 46-year-old male, comes to the office complaining of fatigue. Vital Signs BP: 120/85 mm Hg Temp: 98.2°F (36.8°C) RR: 12/minute HR: 65/minute, regular

History HPI: 46 yo M c/o fatigue × 3 months. #Fatigue began after unsuccessful attempt to save his friend after a car accident. #Constant fatigue throughout the day. #Low energy. #Decreased concentration that is negatively affecting job as accountant. #Decreased appetite, but gained 6 lbs over 3 months. #Multiple awakenings and difficulty staying asleep due to recurrent nightmares about accident. #Feels sleepy throughout the day. #Feelings of being depressed and helpless. #Passive suicidal ideation but no suicide plans/attempts. #Cold intolerance. #Hair loss. #Loss of interest in sex. #No constipation. ROS: Negative except as above. Allergies: NKDA. Medications: None. PMH: Urethritis (possibly chlamydia), treated 5 months ago. PSH: None. SH: 1 PPD for 25 years, 2 beers/month. History of unprotected sex with multiple female partners. FH: Noncontributory.

C44/ Jay Keller, a 49-year-old male, comes to the ED complaining of passing out a few hours earlier. Vital Signs BP: 135/85 mm Hg Temp: 98.0°F (36.7°C) RR: 16/minute HR: 76/minute, regular

History HPI: 49 yo M c/o 1 episode of syncope that occurred a few hours ago. He was taking the groceries to the car with his wife when he suddenly felt lightheaded, had palpitations, lost consciousness, and fell down. He was unconscious for several minutes. His wife recalls that his arms and legs started shaking for 30 seconds after he fell down. He denies subsequent confusion, weakness or numbness, speech difficulties, tongue biting, or incontinence. ROS: Negative except as above. Allergies: NKDA. Medications: HCTZ, captopril, aspirin, atenolol. PMH: Hypertension for the past 15 years; MI 1 year ago. PSH: Appendectomy. SH: 1 PPD for 25 years; quit smoking 1 year ago. Drinks 3-4 beers/week, CAGE 0/4, no illicit drugs. FH: Father died from an MI at age 55.

C3/ Rick Meyer, a 51-year-old male construction worker, comes to the office complaining of back pain. Vital Signs BP: 120/85 mm Hg Temp: 98.2°F (36.8°C) RR: 20/minute HR: 80/minute, regular - XR—L-spine - MRI—L-spine - Rectal exam - PSA

History HPI: 51 yo M construction worker c/o low back pain that started after he lifted heavy boxes 1 week ago. The pain is 8/10 and sharp, and it radiates to the left thigh and sometimes to the left foot. Pain worsens with movement, cough, and sitting for a long time. It is relieved by lying still and partially by ibuprofen. He denies urinary/stool incontinence or weakness/loss of sensation in the lower extremities. No fever, night sweats, or weight loss. He does report difficulty urinating and incomplete emptying of the bladder for 6 months as well as a 1-year history of intermittent low back pain. The pain is exacerbated by sitting for long periods but is relieved by sitting after ambulation. ROS: Negative except as above. Allergies: Penicillin, causes rash. Medications: Ibuprofen. PMH: None. PSH: None. SH: 1 PPD for 18 years, 1-2 beers on weekends, CAGE 0/4. FH: Noncontributory.

C21/ Gail Abbott, a 52-year-old female, comes to the office complaining of yellow eyes and skin. Vital Signs BP: 130/80 mm Hg Temp: 98.3°F (36.8°C) RR: 15/minute HR: 70/minute, regular

History HPI: 52 yo F c/o yellow skin and eyes × 3 weeks. # Light-colored stool and dark urine. # 3/10 RUQ pain, dull, intermittent (daily), no radiation, unrelated to meals, relieved by Tylenol. # Fatigue. # Anorexia. # Pruritus up to 7/10 in severity. # Nausea. # Recent travel to Mexico. # History of blood transfusion 20 years ago. # No diarrhea, constipation, or weight loss. - ROS: Negative except as above. -Allergies: Penicillin, causes rash. - Medications: Tylenol, Synthroid. PMH: Hypothyroidism. - PSH: 2 C-sections, tubal ligation. - SH: No smoking, 1-2 glasses of wine/day for 30 years, CAGE 0/4, no illicit drugs. Sexually active with husband only. - FH: Father died of pancreatic cancer at age 55. No other FH of GI cancer.

C22/ Edward Albright, a 53-year-old male, comes to the ED complaining of dizziness. Vital Signs BP: 135/90 mm Hg Temp: 98.0°F (36.7°C) RR: 16/minute HR: 76/minute, regular

History HPI: 53 yo M c/o intermittent dizziness × 2 days. # Sensation of room spinning around him. #Occurs during day when getting up or lying down. #Episodes last 20-30 minutes and are progressively getting worse. # Left-sided hearing loss since yesterday. #Nausea and vomiting. #Watery, nonbloody diarrhea × 3 days that has since resolved. # No tinnitus, fullness in ear, ear discharge, headache, or head trauma. #No recent URI. ROS: Negative except as above. Allergies: NKDA. Medications: Furosemide, captopril. PMH: Hypertension, diagnosed 7 years ago. PSH: Appendectomy. SH: No smoking, 2-3 beers/week, no illicit drugs. FH: Noncontributory.

C26 Marilyn McLean, a 54-year-old female, comes to the office complaining of persistent cough. Vital Signs BP: 120/80 mm Hg Temp: 99.5°F (37.5°C) RR: 15/minute HR: 75/minute, regular

History HPI: 54 yo F with PMH of chronic bronchitis c/o worsening cough × 1 month. Chronic cough for years. 2 teaspoons of yellowish phlegm with streaks of blood. Dyspnea on exertion. Fever and sweats at night. Fatigue. Decreased appetite, 6-lb unintentional weight loss over 2 months. Exposure to TB as nurse's aide working in nursing home. Last PPD: 1 year ago and negative. No chest pain, chills, or wheezing. No recent travel. ROS: Negative except as above. Allergies: NKDA. Medications: OTC cough syrup, multivitamins, albuterol inhaler. PMH: Per HPI. PSH: Tonsillectomy and adenoidectomy, age 11. SH: 1-2 PPD for 35 years; stopped smoking 2 weeks ago. No EtOH. Sexually active with husband only. FH: Noncontributory.

Opening Scenario James Miller, a 54-year-old male, comes to the clinic for hypertension follow-up. Vital Signs BP: 135/88 mm Hg Temp: 98.0°F (36.7°C) RR: 16/minute HR: 70/minute, regular

History HPI: 54 yo M presents for follow-up of his hypertension that was diagnosed last year. He was initially started on HCTZ; propranolol was added 6 months ago. He is fairly compliant with his medications. He does not monitor his blood pressure at home. His last blood pressure checkup was 6 months ago. He is feeling well except for erectile dysfunction and decreased libido noted 4 months ago. No leg claudication or any previous history of heart problems, stroke, TIA, or diabetes. No marital or work problems. No depression, anxiety, appetite or weight changes, or history of trauma. ROS: Negative except as above. Allergies: NKDA. Medications: HCTZ, propranolol, lovastatin. PMH: Hypertension, hypercholesterolemia diagnosed 1 year ago. PSH: None. SH: No smoking, 3-4 beers/week, no illicit drugs. Works as a schoolteacher; married and lives with his wife. FH: Father died of a heart attack at age 50. Mother is in a nursing home due to Alzheimer's diseas

Opening Scenario Kenneth Klein, a 55-year-old male, comes to the clinic complaining of blood in his stool. Vital Signs BP: 130/80 mm Hg Temp: 98.5°F (36.9°C) RR: 16/minute HR: 76/minute, regular

History HPI: 55 yo M c/o bright red blood per rectum. #History of constipation 6 months ago, 2 bowel movements a week. #1 month ago noticed blood mixed with stool with each bowel movement. #2 days ago, tenesmus and watery brown diarrhea mixed with blood. #10-lb weight loss in 6 months despite good appetite. #Diet of junk food and no vegetables. #No urgency, mucus in stool, or pain with defecation. #Denies fevers, chills, nausea, vomiting, abdominal pain, recent history of travel, or contact with ill persons. ROS: Negative except as above. Allergies: NKDA. Medications: Used to take many laxatives (bisacodyl), but stopped after the onset of diarrhea 2 days ago. PMH: Bronchitis 3 weeks ago, treated with amoxicillin. PSH: Hemorrhoids resected 4 years ago. SH: No smoking, no EtOH, no illicit drugs. Sexually active with wife only. FH: Father died of colon cancer at age 55.

C27 William Jordan, a 61-year-old male, comes to the office complaining of fatigue. Vital Signs BP: 135/85 mm Hg Temp: 98.6°F (37°C) RR: 13/minute HR: 70/minute, regular

History HPI: 61 yo M c/o fatigue and weakness. The patient notes that the fatigue and weakness started 6 months ago. He feels tired all day. He has poor appetite and unintentionally lost 8 lbs in the past 6 months. He also complains of occasional nausea and of a vague, deep epigastric discomfort that radiates to the back. This discomfort started 4 months ago and has gradually increased to a severity of 4/10. The discomfort decreases when he leans forward and increases when he lies on his back. There is no relationship of the pain to food. No changes in bowel movement regularity, but he has recently noticed more foul-smelling, greasy-looking stools. He denies blood in the stool. He feels sad sometimes, has lost interest in things that he used to enjoy, wakes up unusually early in the morning, and complains of low energy and concentration that have affected his daily activities and work. The patient denies suicidal ideation or plans. No feelings of guilt or worthlessness. ROS: Negative except as above. Allergies: NKDA. Medications: Tylenol. PMH: None. PSH: Appendectomy at age 16. SH: 1 PPD for 30 years; stopped 6 months ago. Drinks 2 beers daily and 3−4 beers on weekends. Sexually active with his wife. FH: Father with diabetes, died accidentally. Mother died from breast cancer

C11 Oliver Jefferson, a 62-year-old male, comes to the office complaining of hoarseness. Vital Signs BP: 115/75 mm Hg Temp: 99.9°F (37.7°C) RR: 16/minute HR: 74/minute, regular --------- Diagnostic Workup: Laryngoscopy ESR CT—chest and neck U/S—neck

History HPI: 62 yo M c/o hoarseness × 3 months. Painless, gradually getting worse. Mild fever, fatigue, and "lump in my throat." Poor appetite; lost 10 lbs in 3 months. History of flu 4 weeks ago. ROS: Negative except as above in addition to heartburn. Allergies: None. Medications: None. PMH: High cholesterol. PSH: None. SH: Drinks 3 glasses of wine/day/30 years; smoked 30 packs/year; CAGE (0/4). History of voice overuse (worked as a teacher for 20 years). FH: Mother with hypothyroidism, father with lung cancer.

32/ Virginia Black, a 65-year-old female, comes to the clinic complaining of forgetfulness and confusion. Vital Signs BP: 135/85 mm Hg Temp: 98.0°F (36.7°C) RR: 16/minute HR: 76/minute, regular

History HPI: 65 yo F c/o difficulty remembering × 1 year, after death of husband. # Progressively worsening memory. # Affects daily activities (bathing, feeding, toileting, dressing, transferring into and out of chairs and bed, shopping, cooking, managing money, using the telephone, cleaning the house). # Transient orthostatic lightheadedness with frequent falls, 1 head injury without medical attention. # Upset due to memory difficulty. #Weight loss, no appetite. #No headache, visual changes, gait problems, difficulty sleeping, or urinary incontinence. ROS: Residual weakness in left arm after a stroke. Allergies: NKDA. Medications: HCTZ, aspirin, transdermal nitroglycerin. PMH: Hypertension, stroke, MI. The patient cannot remember exactly when she had them. PSH: Partial bowel resection due to obstruction many years ago. Patient does not remember how long ago this occurred. SH: No smoking, no EtOH, no illicit drugs. She is a widow (husband died 1 year ago), is retired, lives with her daughter, and has a good support system (family, friends). FH: Noncontributory.

38/ Charles Andrews, a 66-year-old male, comes to the clinic complaining of a tremor. Vital Signs BP: 135/85 mm Hg Temp: 98.6°F (37°C) RR: 16/minute HR: 70/minute, regular

History HPI: 66 yo M c/o right hand tremor for 6 months. It occurs at rest and seems to be getting worse. The tremor is exacerbated by fatigue. There are no alleviating factors (he does not drink alcohol). Reducing his caffeine intake to 1 cup of coffee daily did not seem to help. He denies associated symptoms but does say that his wife complains that he has "slowed down" since retiring last year. Specifically, he seems to be walking more slowly recently (time course unspecified, but within the past year). He had a hand tremor when very fatigued back in college, but it was bilateral and faster than his present tremor. ROS: Negative except as above. Allergies: NKDA. Medications: Albuterol MDI prn (no use in past year). PMH: High cholesterol, treated with diet. Mild asthma. SH: No smoking, no EtOH, no illicit drugs. He is a retired chemistry professor, married and lives with his wife. FH: Father may have had a tremor.

C12/ Opening Scenario Carol Holland, a 67-year-old female, comes to the office complaining of neck pain. Vital Signs BP: 115/75 mm Hg Temp: 98.0°F (36.7°C) RR: 16/minute HR: 74/minute, regular ________ XR—C-spine MRI—C-spine Nerve conduction studies

History HPI: 67 yo F with 2 days of neck pain and left upper extremity numbness. - Started after quick rotation to the left. - Sharp pain 2/10 at rest, 8/10 with motion. - Associated left arm numbness. Denies weakness. - 10-lb weight loss in past 6 months attributed to poor appetite. - No recent trauma or heavy lifting. - No dyspnea, fevers, night sweats. - Screenings up to date. ROS: Negative except as above. Allergies: NKDA. Medications: Calcium and vitamin D supplements. PMH: Osteopenia on last DEXA. PSH: None. SH: Social alcohol use, no tobacco or drugs. Retired magazine editor. FH: Mother with osteoporosis, father with MI at 68.

C17/ Opening Scenario Paul Stout, a 75-year-old male, comes to the office complaining of hearing loss. Vital Signs BP: 132/68 mm Hg Temp: 98.4°F (36.9°C) RR: 18/minute HR: 84/minute, regular

History HPI: 75 yo M c/o bilateral hearing loss for all sounds that started 1 year ago and is progressively worsening. He had cerumen removal 1 month ago with moderate improvement. He reports occasional tinnitus and rare headaches. He notes that words sound jumbled in crowded places or when he is watching TV. He denies inserting any foreign body into the ear canal. No ear pain, no ear discharge, no vertigo, no loss of balance. No history of trauma to the ears; no difficulty comprehending or locating the source of sounds. ROS: Negative. Allergies: Penicillin, causes rash. Medications: HCTZ, aspirin (for 25 years). PMH: Hypertension. UTI 1 year ago, treated with antibiotics. PSH: None. SH: No smoking, no EtOH, no illicit drugs. Retired veteran. Sexually active with wife only. FH: No history of hearing loss.

Opening Scenario The mother of Josh White, a 7-month-old male child, comes to the office complaining that her child has a fever. Examinee Tasks 1. Take a focused history. 2. Explain your clinical impression and workup plan to the mother. 3. Write the patient note after leaving the room.

History HPI: History obtained from mother. The patient is a 7-month-old M with fever × 1 day. Temperature recorded by forehead thermometer at home reached 101°F yesterday. The child has been tired, irritated, and breathing rapidly for the past day. The mother denies any abdominal retractions or nasal flaring. The mother also notes rhinorrhea and refusal of breast and baby food. The child has a history of sick contact with his 3 yo brother, who had a URI 1 week ago that has since resolved. He attends day care. No cough, ear pulling, ear discharge, or rash. ROS: Negative except as above. Allergies: NKDA. Medications: Tylenol. PMH: Jaundice in the first week of life. PSH: None. Birth history: 40-week vaginal delivery with no complications. Dietary history: Breast-feeding and supplemental vitamins. Immunization history: UTD. Developmental history: Last checkup was 2 weeks ago and showed normal weight, height, and develop- mental milestones.

C30 The mother of Angelina Harvey, a 2-year-old female child, calls the office complaining that her child has noisy and strange breathing.

History HPI: The source of information is the patient's mother. The mother of a 2 yo F c/o her child suddenly developing noisy breathing that is getting progressively worse. The child was playing with her toys when she developed the noisy breathing. The sound is consistent, best heard on inhalation, and similar to that of a washing machine. There is no relation to posture. It is associated with a nonproductive cough without any associated hemoptysis, tachypnea, drooling, or bluish discoloration of the skin. Her vaccinations are up to date. ROS: Negative. Allergies: NKDA. Medications: None. PMH: Uncomplicated spontaneous vaginal delivery. PSH: None. FH: Noncontributory.

18/ The mother of David Whitestone, a 5-day-old male child, calls the office complaining that her child has yellow skin and eyes. Examinee Tasks 1. Take a focused history. 2. Explain your clinical impression and workup plan to the mother. 3. Write the patient note after leaving the room.

History HPI: The source of information is the patient's mother. The mother of a 5-day-old M c/o her child having yellow discoloration of the eyes and skin for 2 days. It has not worsened. The child is awake, responsive, playful, and active. He is breast-fed. His stomach is soft and he has 2-3 daily bowel movements. The color of his stools is brown. She denies any h/o recent fever, vomiting, seizure, URI, or breathlessness. There is no noticeable dryness of the mouth. He is wetting 7-8 diapers per day every 3-4 hours. He was delivered vaginally at full term. The mother did receive antibiotics for a positive culture before delivery. The blood group of both mother and neonate is B positive, while that of the father is A positive. ROS: Negative. Allergies: NKDA. Medications: None. PMH: None. PSH: None. FH: His elder sister was hospitalized after the first week of birth for jaundice.

C40/ The mother of Theresa Wheaton, a 6-month-old female child, calls the office complaining that her child has diarrhea. Examinee Tasks 1. Take a focused history. 2. Explain your clinical impression and workup plan to the mother. 3. Write the patient note after leaving the room.

History HPI: The source of information is the patient's mother. The mother of a 6-month-old F c/o her child having 1 day of diarrhea, weakness, and drowsiness. The child has had 6 watery brown bowel movements per day. There was no blood in her stool, but she has not urinated since yesterday. She received Tylenol without improvement. The mother reports the child's temperature as 100.5°F and adds that her mouth is dry. The child has no known sick contacts but is in day care. The mother denies any vomiting, lethargy, excessive sleeping, abnormal behavior, or recent URIs. The child had a normal checkup with her pediatrician 2 weeks ago and is up to date on her immunizations. She has a diet of formula with iron and rice cereal at night with occasional juice. ROS: Negative. Allergies: NKDA. Medications: None. PMH: Uncomplicated spontaneous vaginal delivery. PSH: None. FH: Noncontributory.

C41/ The mother of Adam Davidson, an 8-year-old male child, comes to the office concerned that her son continues to wet the bed. Examinee Tasks 1. Take a focused history. 2. Explain your clinical impression and workup plan to the mother. 3. Write the patient note after leaving the room.

History HPI: The source of the information is the patient's mother. The mother of an 8 yo M c/o her child continuing to wet the bed several times a week. The child has never had a significant period of continence at night. He has no hematuria, fever, or urgency. There is possible dysuria, although the mother is not sure. The mother denies that the child c/o abdominal pain or constipation. The child does not snore or wake up multiple times during the night. There are no exacerbating factors, and there have been no major lifestyle changes or stresses in the family. The problem is causing distress for the child, who has been avoiding sleepovers, as well as for the mother, who is worried about the possibility of an underlying medical condition. ROS: Negative. Allergies: NKDA. Medications: None. PMH: None. PSH: None. Birth history: Normal. Developmental history: Normal. FH: Positive family history of male nocturnal enuresis.

Closure:

Mr. Green, you may have a fractured bone, a simple sprain, or a dislocation of the shoulder joint. We will need to obtain an x-ray of your shoulder and arm to make a diagnosis, and more precise imaging studies such as an MRI may be necessary as well. Your safety is my primary concern, and I am here to offer you help and support whenever you need it. Sometimes living with a family can be stressful for the whole household. Have you ever considered moving to an assisted-living community or to an apartment complex for seniors? If you are interested, I can arrange a meeting with our social worker, who can assess your social situation and help you find the resources you need. Do you have any questions for me?

Closure

Mr. Stern, the palpitations and sweating you have experienced are most likely due to episodes of low blood sugar, which may have resulted from a higher-than-normal dose of insulin or from skipping or delaying meals. The numbness you describe in your feet is probably related to the effect of diabetes on your nervous system; better control of your blood sugar may help improve this problem. Many factors, including diabetes, can cause the erection difficulties you describe. I will need to perform an examination of your genital area and run some blood tests, and at some point we may also need to conduct some more complex tests to identify the cause of your problems. Do you have any questions for me?

Diagnostic Workup: Urine hCG Pelvic and breast exams Prolactin, TSH LH/FSH

Mrs. Garrison, there are a few reasons you may not be having regular periods. The first thing we need to do is determine whether you are pregnant. We can do that with a simple urine test. The other thing we need to do is conduct breast and pelvic exams, especially since you have had some nipple discharge, and look for any signs of menopause. Menopause is highly unlikely at your age, but on rare occasions it may occur. A blood test to measure your hormone levels will also help us determine if you are menopausal or have a hormonal imbalance. This will give us a good start in figuring out why you haven't had your period, and we will go from there. Do you have any questions for me?

Closure

Mrs. Holland, given your symptoms, I am concerned that you may have a pinched nerve in your neck. Since you have a history of low bone density, I want to make sure your symptoms weren't caused by a fracture. And although it's unlikely, certain cancers may spread to the neck and spine and cause similar symptoms. I want to run some tests to rule out this possibility. I would like to start by getting an x-ray of your neck. Do you have any other questions for me?

Closure

Ms. Melton, I am really sorry for what happened to you. I want to emphasize that it is not your fault, and you should not feel guilty about it. I recommend that you report the incident to the police. In the meantime, I will need to do a pelvic examination to make sure you have no injuries in the genital area. In addition, I will need to collect some specimens and swabs from your body and genital area so that they can be used as evidence if you choose to file charges, and also to look for STDs. We will run some blood tests for potential STDs and will order a pregnancy test and some x-rays. If your pregnancy test is negative, we will offer you some options for emergency contraception. It would also be prudent to give you some antibiotics to protect you from infections. Finally, I can have our social worker come talk to you and provide you with phone numbers for support groups and other resources. Do you have any questions for me?

Diagnostic Workup MRI—brain

Sample Closure Mr. Andrews, I am sorry to have to tell you this, but on the basis of your history and physical exam, it would appear that you have Parkinson's disease. Your symptoms may improve with medications, but eventually they will return. One indicator of disease progression involves looking closely at your handwriting. Do you think you could bring an old sample of your handwriting with you on your next visit? You should also know that about 25% of the time, patients with your symptoms do not have Parkinson's disease. For this reason, I would like to run a few tests, including some imaging studies of your head and some blood tests. Although we won't have those results before you leave today, I will print out a comprehensive patient pamphlet that will give you resources to help answer your questions as they come up. I want you to know that I will be here to treat you and to help you every step of the way. Do you have any questions for me?

Diagnostic Workup LP—CSF analysis CBC Electrolytes

Sample Closure Mrs. Weber, it sounds as though your child has indeed had a seizure. The most likely cause is her high fevers; seizures caused by fevers happen in many young children. However, because there are many types of seizures, I would like to examine your child and also do some tests to make sure that the seizures are not being caused by something more serious, like meningitis. Do you have any questions for me?

Diagnostic Workup: Dix-Hallpike maneuver Audiometry MRI—brain

Sample Closure Mr. Albright, the dizziness you are experiencing may be due to a problem in your ears or brain, or it may result from low blood pressure. We will have to run some tests to pinpoint the source of your symptoms. These may include blood tests, a hearing evaluation, and an MRI that will provide detailed images of your brain. Until we find the cause of your problem, you should be careful when you stand up quickly or walk unaccompanied, and you should use hand railings whenever possible. Do you have any questions for m

Diagnostic Workup -CBC with peripheral smear -Monospot test -Anti-EBV antibodies -HIV antibody and viral load -Throat culture

Sample Closure Mr. Davis, it is likely that you have acquired the same infection your girlfriend had. This may be no more than a transient viral infection, or it may represent a more serious illness such as HIV. We will need to run a few tests to help us make the diagnosis. I recommend that we obtain an HIV test, and we will also need to obtain a throat swab and an ultrasound of your abdomen. In the meantime, I strongly recommend using condoms to avoid an unwanted pregnancy and to prevent STDs. Since infectious mononucleosis is one of the diseases that might account for your symptoms, I also recommend that you avoid contact sports for at least 3 weeks because of the possible risk of traumatic rupture of your spleen, which could be fatal. Also, since cigarette smoking is associated with a variety of diseases, I advise you to quit smoking; we have many ways to help you if you are interested. Do you have any questions for me?

Diagnostic Workup Urine toxicology Electrolytes CPK Urine myoglobin Mental status exam

Sample Closure Mr. Edwards, your symptoms could be caused by your illicit drug use, or they may be the result of a mental problem or even a medical condition. We will run some tests to try to clarify your condition. In addition, I recommend that you stop using illicit drugs and quit smoking. Do you have any questions for me?

Diagnostic Workup CXR—PA and lateral PPD or QuantiFERON Gold CBC

Sample Closure Mr. Emanuel, your physical examination is normal, but your cough may raise concern for some possible medical problems. We need to order some tests to make sure you are free of any serious medical conditions, and if we find anything, we will treat it right away. Since you just came here from Africa and you have never been tested for TB, we need to rule out pulmonary tuberculosis, not only because it is harmful to you but also because you may transmit it to your future coworkers. The other issue I want to talk to you about is your smoking. It puts you at increased risk of heart and lung disease, and I strongly urge you to quit. Do you have any questions?

Diagnostic Workup XR—right ankle/foot Bone scan MRI—right ankle/foot

Sample Closure Mr. Foreman, the most likely cause of your heel pain is plantar fasciitis, which is the most common cause of pain on the bottom of the heel. It typically resolves over a few months, with conservative treatment consisting of stretching, massage, NSAIDs, and avoidance of painful activities. I would highly suggest that you decrease the amount of running you do and avoid walking barefoot on hard surfaces until this improves. We will get an x-ray today to help confirm that there is no obvious fracture or foreign body and to look for possible bone spurs. If you would like, I can send you to physical therapy to help you get started on these exercises. If your symptoms are not responsive to this treatment over the next 2 months, we may consider a bone scan to rule out a stress fracture. Do you have any questions for me?

Diagnostic Workup CXR CBC with differential Sputum Gram stain and culture

Sample Closure Mr. Glenn, your cough is most likely due to an infection that can be either bacterial or viral. The chest pain you are experiencing is probably due to irritation of your lung membranes by an infection. Some of these infections can be more common with HIV, and given your sexual history, I recommend that we test for it. Another reason for your cough may be acid reflux, more commonly known as heartburn. We are going to test your blood and sputum and will obtain a chest x-ray to help us make a definitive diagnosis. We may also need to obtain a PPD to test for tuberculosis if your cough is persistent. In the meantime, I strongly recommend that you use condoms during intercourse to prevent STDs such as HIV as well as to prevent unwanted pregnancies. Do you have any questions for me?

Closure

Sample Closure Mr. Jefferson, there are a few things that could be causing your hoarseness, such as an infection or a benign or cancerous growth. To find out, I need to do a laryngoscopy, which is a procedure to view the inside of your throat, and a CT scan of your neck. These tests will likely reveal the underlying problem. Since cigarette smoking is dangerous to your health, I advise you to quit smoking; we have many ways to help you if you are interested. I also recommend that you stop drinking, as alcohol and smoking are associated with laryngeal cancer. Do you have any questions for me?

Diagnostic Workup CBC, stool for occult blood Glucose Fecal fat studies Amylase, lipase AST/ALT/bilirubin (direct, indirect, and total)/ alkaline phosphatase CT—abdomen

Sample Closure Mr. Jordan, your symptoms are consistent with a few different diagnoses. They may be caused by an ulcer that would resolve with a course of antibiotics and acid suppressors, or they may have a more serious cause, such as pancreatic cancer. I am going to schedule you for an abdominal CT scan that may reveal the source of your pain, and I will also run some blood tests. I know you are concerned about your upcoming vacation, but the results of your tests should be back within a few days, and they should give us a good idea what is wrong with you. In the meantime, our social worker can meet with you to help you find ways to cope with the stress you have been experiencing in your life. Do you have any questions for me?

Diagnostic Workup CBC Electrolytes ECG and Holter or event monitor CT—head or MRI—brain EEG

Sample Closure Mr. Keller, I need to run some tests to determine the reason you passed out this morning, so I am going to get a CT scan of your head to look for bleeding or masses, and I will then order some blood tests to look for infections or electrolyte abnormalities. You mentioned that your heart was racing just before you passed out, so I will also ask you to wear a heart monitor for 24 hours. Doing so is just like having a constant ECG, and it will allow us to detect any abnormal heartbeats you might have. We will start with these tests and then go from there. Do you have any questions for me?

Diagnostic Workup -Rectal exam, stool for occult blood -Colonoscopy -Stool for C difficile PCR -Fecal leukocytes -CBC -Anoscopy -Flexible -proctosigmoidoscopy

Sample Closure Mr. Klein, the symptoms you describe may be due to readily treatable problems, such as hemorrhoids, an infection in your colon, or diverticulosis. However, they may also be a sign of more serious disease, such as colorectal cancer. It is crucial that we run some blood tests, a stool exam, and probably a colonoscopy, which involves looking at your colon through a thin tube that contains a camera. I will also need to perform a rectal exam today. Once we make a diagnosis, we should be able to treat your problem. Do you have any questions for me?

Diagnostic Workup Genital and rectal exams Serum glucose Testosterone level Prolactin, TSH, LH/FSH Ferritin MRI—brain Doppler U/S—penis Dynamic cavernossography

Sample Closure Mr. Miller, your blood pressure level was 135/88 when we measured it earlier today, which is close to our target of 130/80. However, it would be even better if we could get it down to around 120/80. Fortunately, that should be feasible with lifestyle changes such as decreasing your salt and fat intake and increasing the amount of exercise you are doing. As for your problems with your erection, this is a very common side effect of one of the blood pressure medications you are taking. For this reason, I would like to give you a medication other than propranolol to control your blood pressure. I am also going to order some blood tests to make sure that your problem is not due to any other medical condition. In addition, I would like to perform a genital exam as well as a rectal exam to assess your prostate. Do you have any questions for me?

Diagnostic Workup TSH CBC HIV antibody

Sample Closure Mr. Mitchell, it appears that your life has been very stressful lately, and my suspicion is that you may be clinically depressed. Before I make a definitive diagnosis, however, I would like to order some blood tests, including one for HIV, as you have risk factors for sexually transmitted diseases. Once we have completed these tests, we should have a better idea of what is causing your fatigue. In the meantime, I strongly recommend that you quit smoking, exercise regularly, and participate in activities that you find relaxing. I would also like you to promise me that if you feel like hurting yourself, you will call someone who can help you or go immediately to an emergency department. Do you have any questions for me?

Diagnostic Workup - Audiometry - Tympanography - Brain stem auditory evoked potentials

Sample Closure Mr. Stout, I know that you are concerned about your problem. I can confirm that you do have some hearing loss. I would like to run several tests, including some blood tests. I would also like you to stop taking aspirin, because this may be contributing to your hearing loss. I will refer you to an audiometrist, who will assess you for a hearing aid. Do you have any questions for me?

Diagnostic Workup AST/ALT/bilirubin/alkaline phosphatase U/S—RUQ abdomen Viral hepatitis serologies

Sample Closure Mrs. Abbott, the symptoms you describe are usually due to a disorder either in the liver itself or in the bile ducts, which are physically close to your liver. We will have to run some blood tests and conduct imaging studies such as ultrasound to get a better idea of what is going on. Once we find the cause of your problem, we can come up with an appropriate treatment plan. Until then, I recommend that you stop drinking and limit your use of Tylenol, as both may harm your liver. Do you have any questions for me?

Diagnostic Workup CT—head or MRI—brain EEG or SPECT CBC Serum B12, TSH, RPR Electrolytes, calcium, glucose, BUN/Cr

Sample Closure Mrs. Black, your symptoms may be due to a number of disorders that can affect the brain, many of which are treatable. We need to run some tests to identify the cause of your problem. I would also like to ask your permission to speak with your daughter. She can help me with your diagnosis, and I can answer any questions she might have about what is happening to you and how she can help. I would also like you and your family to meet with the social worker to assess at-home supervision and safety measures. The social worker will inform you of resources that are available in the community to help you. If you would like, I can remain in close contact with you and your family to provide additional help and support. Do you have any questions for me?

Closure

Sample Closure Mrs. Clark, it sounds as if your symptoms are due to a migraine headache, so the first thing I will do is prescribe some medications that will alleviate your pain. To ensure that there isn't something else going on, however, I would like to get a CT scan of your head to rule out a mass or vascular problem as the cause of your headache. A blood test may also show if you have problems other than migraine. Do you have any questions for me?

Diagnostic Workup -Genital exam -UA -Urine culture

Sample Closure Mrs. Davidson, your son's condition is probably an isolated symptom, but I would still like to examine him and run some tests to make sure he does not have an underlying infection or a more serious medical problem. We can then discuss his treatment options. Do you have any questions for me?

Diagnostic Workup -TSH -Serum lithium level -Fasting glucose, cholesterol, triglycerides

Sample Closure Mrs. Grant, most smokers gain an average of 5 pounds when they quit. You have gained 20 pounds over 3 months. This may have resulted from your smoking cessation, but bear in mind that the health risk posed by smoking is far worse than the risk you might incur from excessive weight gain. In addition, there may be other reasons for your weight gain; for example, it may be related to your thyroid gland, or it may be a side effect of the lithium you're taking. I would like to draw some blood to measure your thyroid function and lithium levels. In the meantime, in addition to stopping smoking, you should continue to pursue a healthier lifestyle. Try to decrease the fatty foods you eat and increase the healthy ones, such as fruits and vegetables. Exercising only 30 minutes 3 times a week can also improve your health. Do you have any questions for me?

Diagnostic Workup ABG CXR—PA and lateral XR—neck, AP and lateral CBC with differential Bronchoscopy Direct laryngoscopy

Sample Closure Mrs. Harvey, on the basis of the information I have gathered from you, I'm considering the possibility that your daughter might have swallowed a foreign body. However, the possibility that an infection might be causing her problem needs to be ruled out. Right now, I feel that your daughter needs emergency medical attention. Since you do not have access to transportation, I strongly suggest that you call 911 immediately and bring her to the medical center. In the meantime, I suggest that you avoid putting a finger in her mouth or performing any blind finger sweep, as doing so may cause the foreign body to become more deeply lodged if it is actually present. If you observe significant respiratory compromise or choking, perform the Heimlich maneuver by thrusting your daughter's tummy with sudden pressure. I hope you understood what we have discussed. Do you have any questions or concerns? Okay, I will see you once you get to the hospital.

Diagnostic Workup PPD or QuantiFERON Gold CBC Blood cultures Sputum Gram stain, AFB smear, routine and mycobacterial sputum cultures, and cytology CXR—PA and lateral CT—chest Bronchoscopy Lung bio

Sample Closure Mrs. McLean, your cough may be due to a lung infection that can be treated with antibiotics, or it may result from something more serious, such as cancer. We will need to obtain some blood and sputum tests as well as a chest x-ray to identify the source of your cough. In addition, we may find it necessary to conduct more sophisticated tests in the future. The fact that you work in a nursing home puts you at risk for acquiring tuberculosis, so we are going to test you for that as well. I would also recommend that you adhere to standard respiratory precautions while working with patients who are infected with TB. Do you have any questions for me?

Clossure

Sample Closure Mrs. Smith, there are a number of disorders that can cause pain similar to what you have described. Pain of this type is most commonly due to an ulcer, an abdominal infection, or a gallstone. We will have to run some tests to confirm the diagnosis and to rule out more serious illness. These tests will include a rectal exam, an ultrasound of your abdomen, blood tests, and possibly an upper endoscopy, which examines your stomach by means of a tiny camera passed through your mouth. Once we have made the diagnosis, we will be able to treat your condition and help alleviate your pain. Do you have any questions for me?

Diagnostic Workup Pneumatic otoscopy LP—CSF analysis CBC with differential, blood culture, UA and urine culture Throat culture Platelets, PT/PTT, D-dimer, fibrin split products, fibrinogen

Sample Closure Mrs. Sterling, it appears that your child is suffering from an infection that may be viral or bacterial. She may be suffering from an ear infection or something more serious. A physical exam and some blood tests will be needed to identify the source of infection and the type of virus or bacteria involved. Although viral infections generally clear on their own, most bacterial infections require antibiotics; however, such infections generally respond well to treatment. Do you have any questions for me?

Diagnostic Workup CBC with differential Blood culture UA and urine culture CXR Respiratory viral panel Pneumatic otoscopy

Sample Closure Mrs. White, your child's fever may be due to a simple upper respiratory tract infection, or it may be attributable to an ear infection caused by a virus or certain types of bacteria. I would like to examine him so that I can better determine the cause of his fever and exclude more serious causes, such as meningitis. In addition to a detailed physical exam, your baby may need some blood tests, a urinalysis, and possibly a chest x-ray. Do you have any questions for me?

Diagnostic Workup Total and indirect bilirubin Blood typing Direct Coombs test CRP

Sample Closure Mrs. Whitestone, given the information you have provided, I'm considering the possibility of physiologic or natural jaundice. This condition usually peaks on day 4 or 5 after birth and then gradually disappears within 1-2 weeks. However, breast- feeding, some other pathologic conditions, and certain birth defects can also cause jaundice in infants, and these need to be ruled out. I suggest that you bring your child to the medical center for further evaluation. I hope you understood what we discussed today. Do you have any concerns or ques

Diagnostic Workup Urine hCG Pelvic exam Cervical cultures U/S—abdomen/pelvis CT—abdomen/pelvis CBC

Sample Closure Ms. Anderson, your symptoms may be due to a problem with your reproductive organs, such as an infection in your fallopian tube or a cyst on your ovary. They might also result from a complicated pregnancy, which could be indicated if your pregnancy test comes back positive. Another possibility is an infection in your appendix, which could require surgery. To ensure an accurate diagnosis, we will need to run some tests, including a blood test, a urinalysis, a pregnancy test, and possibly a CT scan of your abdomen and pelvis. I will also need to perform rectal and pelvic exams. Since cigarette smoking is associated with a variety of diseases, I advise you to quit smoking; we have many ways to help you if you are interested. I also recommend that you use a condom every time you have intercourse to prevent STDs, including HIV, and to avoid pregnancy. Our social worker can meet with you to discuss your social situation, and she can offer you a variety of resources. Do you have any questions for me?

Diagnostic Workup: Serum glucose, HbA1c CBC Serum iron, ferritin, TIBC, serum B12 UA Electrolytes

Sample Closure Ms. Lee, I am concerned about your safety and your relationship with your husband. I would like you to know that I am available for help and support whenever you need it. Although everything we discuss is confidential, I must involve child protective services if I have reason to believe that your children are being abused. I will bring back some telephone numbers and contact information for you regarding where to go for help if you or your children are in a crisis or if you just want someone to talk to. I am also concerned about your frequent urination and thirst. I will run a simple blood test to see if you have any problems with your blood sugar or your hormones. Do you have any questions?

Diagnostic Workup - Pelvic exam - Wet mount, KOH prep, "whiff test" Cervical cultures (chlamydia and gonorrhea DNA probes) - Laparoscopy

Sample Closure Ms. McCall, your most likely diagnosis is an infection in the vagina or cervix. However, there are other, less common causes of your problem. I can't make a diagnosis until I do a pelvic exam and take a look at what I find under a microscope. I will also take a cervical swab and send it for gonorrhea and chlamydia testing. Do you have any questions for me?

Diagnostic Workup CBC with differential Immunologic testing (eg, ANA titer, anti- dsDNA, RF, anti-CCP) Knee aspiration with Gram stain, culture, and inspection for crystals XR—left knee and both hands

Sample Closure Ms. Moore, there are a few things that could be causing your knee pain, such as gout, an infection, or rheumatoid arthritis. To find out, I would like to obtain fluid from your knee and then draw some blood. Sometimes infections from the pelvis can spread to other parts of your body, such as your knee, and for that reason I would also like to do a pelvic exam. These tests will likely reveal the source of your pain. You mentioned earlier that you don't always use condoms. I know condoms may be difficult to use regularly, but they are important in helping control the spread of STDs. Do you have any questions for me?

Diagnostic Workup TSH, FT3, FT4

Sample Closure Ms. Potter, on the basis of your history and my examination, I think there are a few factors that might be contributing to your sleeping problems. The first is the anxiety and stress you've been experiencing over performing well in college. Although this is perfectly understandable, you may not be able to perform at your best if you don't get a good night's sleep. On the other hand, your problems could stem from your caffeine use, which I urge you to reduce or stop completely. Another possibility has to do with your thyroid function. Sometimes hyperactivity of the thyroid gland can cause some of the symptoms you describe, and the only way to rule this out is through a blood test. In light of your history of snoring, we may need to do a sleep study in the future to rule out sleep apnea. At this point, I encourage you to proceed with the lifestyle changes I have recommended, and I will see you for follow-up to find out how you are doing. Do you have any questions or concerns?

Diagnostic Workup -Rotavirus enzyme immunoassay/norovirus PCR -Electrolytes -Stool leukocytes, culture, ova and parasitology, and pH

Sample Closure Ms. Wheaton, from the information you have given me, I am concerned that your child may be dehydrated. She hasn't urinated since yesterday, and she is weak and drowsy. It is very hard for me to assess her over the telephone, and I do not want to jeopardize her health in any way. For this reason, I am going to ask you to bring her in for a physical exam and a full assessment, and we will then proceed according to what we find on the exam. I understand that you may have problems with transportation, but we are fortunate to have a social worker here who can help you handle these issues. After we are done on the phone, I will transfer your call to him, and he can help you. Do you have any questions for me?